Artigos de revistas sobre o tema "Doctor Foster (Television program)"

As part of an ARC Discovery project to write a history of Australian television from the point of view of audiences, I looked for Australian television fan communities. It transpired that the most productive communities exist around imported programming like the BBC's Doctor Who. This program is an Australian television institution, and I was therefore interested in finding out whether it should be included in an audience-centred history of Australian television. Research in archives of fan materials showed that the program has been made distinctively Australian through censorship and scheduling practices. There are uniquely Australian social practices built around it. Also, its very Britishness has become part of its being — in a sense — Australian. Through all of this, there is a clear awareness that this Australian institution originates somewhere else — that for these fans Australia is always secondary, relying on other countries to produce its myths for it, no matter how much it might reshape them.

This study examined a professional development program aimed at supporting Jewish civics teachers in their efforts to promote empathy among their students toward Israeli Arabs. Previous results indicated an increase in outgroup empathy among teachers who watched and reflected upon clips from a television sitcom. This article focuses on skills teachers developed and strategies they designed and implemented following their experience with empathy processes. Our findings underscore the educative potential of indirect mediated contact in segregated societies, and the importance of developing empathic processes among teachers before they embark on the challenge of supporting their students in such endeavors.

The paper is devoted to the study of the specifics of the communicative behavior of a doctor’s professional linguistic personality in the media discourse. The relevance of the work is determined by the need for a systematic linguistic study of professional communication in new media-discursive conditions, as well as insufficient knowledge of the implementation of the professional linguistic personality of a doctor in the aspect of mediatization of medical discourse. The object of the study is the professional communication of a doctor in the media discourse. The subject of the study is the contexts of a medical TV program, representing the communicative behavior of a doctor’s PNL. The purpose of the study is to identify the discursive specifics of the communicative behavior of the professional language personality of a doctor in a television program about health. The research methodology was discourse analysis, on the basis of which the parameters for describing the doctor’s communicative behavior in the media discourse were determined. The features of doctor’s media communication in telediscourse are revealed taking into account the goals of professional activity and within the framework of the status-role culture of the profession, the processes of transformation of strategic planning of doctor’s communication are analyzed, the hierarchy of the communicative goals of a medical worker in television programs about health is determined. The discursive specificity of the doctor’s communicative behavior in television discourse is characterized. It has been established that the professional linguistic personality of a doctor in the media discourse is a special type of professional linguistic personality that functions in the media environment and is formed by a complex of social and communicative roles of a representative of the medical community and status in the media space.

As time goes by, mass media has become a need that is almost inseparable from humans, one of which is television. Television has now become a means of entertainment for some people, many TV stations are competing to create programs to meet the entertainment needs of their viewers, not infrequently many violations are still broadcast in order to pursue TV program ratings, one of which is the exploitation of women. This research was made based on the many cases of exploitation of women's bodies that occurred in mass media such as television, especially the reality show program 'D'café' trans 7. Seeing this problem, the formulation of the problem in this research is; how women's bodies are exploited on the variety show program D'café on July 1 2021. This research aims to find out cases of exploitation of women, especially in the variety show program D'café trans 7. This research uses a qualitative content analysis method where researchers use data such as images from this verit show program to strengthen the results of this research. In this research, researchers used commodification theory. In the D'café broadcast on July 1 2021, Aspiration and Doctor Boyke were invited with a chat topic about sexual fantasies. The results of this research confirm that the beauty of women's bodies has always been used as a commodity capable of accumulating capital or generating profits. Because women are a very large market in the media industry which is believed to be able to attract many viewers to generate high ratings.

The process of deteriorating television should indeed be done by an expert who is a television expert himself, but because television is a tool that is no longer common for people to know him, many people also have television in their respective homes. Even for television repairs, it is quite expensive, so some people who have televisions can do television maintenance at home. The lack of knowledge possessed by the community can lead to wrong handling of television maintenance / maintenance and this has a fatal impact. Hopefully the existence of this system can help the community in diagnosing the damage to their televisions. In that case they need not bother to call for repairmen or bring in a television repair shop. Here the authors provide solutions to solve the problems that often arise on television. In this study, it discusses how to care for television officers. The research objective is to analyze a desktop-based expert system program that contains the knowledge of an expert / doctor whose truth is believed to have the ability to be able to diagnose the disease from the symptoms of damage that has been damaged by television damage quickly and precisely. The stages of research carried out in this study include literature study, data collection, system design, system creation, system testing. Case Based Reasoning is a method used to build a knowledge-based system. The source of system knowledge is obtained by collecting the handling of cases by an expert / expert. Therefore, many problems in television damage are usually due to the negligence of the television owner himself. The first step in solving a problem is by first identifying the scope of the problem to be resolved, this also applies to any Artificial Intelligence (AI) programming. The results obtained in the study for the diagnosis of conjunctivitis were the value of old cases and new cases which obtained a high weight value, namely 1 from the third case

Background: A physician-scientist refers to a person with dual Medical Doctor (MD) and Doctor of Philosophy (PhD) degrees, i.e., a physician who has acquired medical knowledge and skills as well as scientific knowledge and research abilities. This study examines the background and current status of physician-scientists in Korea and suggests policy directions to foster physician-scientists suitable for Korea.Current Concepts: With the start of the medical graduate school system in 2005, the MD-PhD dual degree program was implemented under the name of “medical scientist”. With the discontinuation of the medical graduate school system, the term “medical scientist” was replaced with “physician-scientist”. The importance of physician-scientists for the development of biomedical research and industry has been consistently emphasized. Therefore, the government has recently initiated a support policy to train physician-scientists.Discussion and Conclusion: To successfully foster physician-scientists in Korea, the following government policy aspects should be strengthened. First, sufficient economic support should be provided so that physician-scientists could immerse themselves in biomedical research. Second, to guarantee stable employment for physician-scientists, a national research institution such as the National Institute of Health in the United States should be established. Finally, the educational programs of the medical schools should be revised to strengthen the research-related knowledge and skills of the medical students.

Nursing leaders are essential in promoting the doctor of nursing practice (DNP)-prepared nurse in various innovative roles (Nichols, O’Connor, & Dunn, 2014). However, according to the recently released RAND study,The DNP by 2015: A Study of the Institutional, Political, and Professional Issues That Facilitate or Impede Establishing a Post-Baccalaureate Doctor of Nursing Practice Program(Auerbach et al., 2014) employers and health care organizations need outreach and data to understand the added competencies and capabilities of DNP-educated nurses. Practicing DNPs are in an excellent position to demonstrate and educate our executive colleagues. The purpose of this article is (a) to foster nursing leadership’s understanding of the uniquely prepared nursing practice doctorate, (b) to illustrate how the DNP-prepared nurse is being integrated/used to their potential within health care systems to maximize clinical and population health outcomes, and (c) to issue a call to action for nursing leadership to engage the DNP-prepared nurse to accomplish organizational goals.

e21015 Background: Narrative Competence is the ability to acquire, interpret and act on the stories of others.[1] Developing this skill can also improve health care practitioner’s sense of empathy and satisfaction with their work.[2] This study’s purpose is to evaluate the impact of a narrative medicine curriculum on medical students’ sense of connection to their patients and humanism in medicine. Methods: During the 2023 academic year, a narrative medicine assignment was introduced to the internal medicine oncology clerkship curriculum at the Yale School of Medicine. Third year medical students attended a training session on narrative medicine skills, interviewed a patient and wrote the patient’s story, and attended a session to read their written narrative. A survey was distributed to students asking for their reflections on the doctor patient relationship and the role of humanism in improving well-being and reducing burn out. Responses were de-identified and thematic analysis of responses was conducted. Results: 58 students participated in the training sessions and 11 (19%) completed a post-workshop free text survey with 5 questions reflecting on the doctor-patient relationship, the role of humanism in medicine, and the curriculum itself. Common themes that emerged include 1) how strong doctor-patient relationships makes medicine more meaningful, uplifting and enjoyable, 2) how seeking out a patient’s story is essential to the doctor-patient relationship and to optimal quality care, and 3) importance of doctor’s exhibiting care and sensitivity and placing diseases in context of their patients’ stories. Reflecting on the role of humanism in medicine, students reported that 1) taking the time to know your patients makes medicine rewarding, meaningful and worthwhile, 2) allows you to empathize and connect with patients more through recognizing their humanity and vulnerability and putting their frustrations in context, and 3) could be healing to both patient and provider. Further directions: Students suggested making the program mandatory, expanding to include pre-clerkship students and students on other clerkships, and providing more time and structure to facilitate interviewing patients and writing up their stories. Conclusions: A curriculum incorporating narrative medicine was effectively integrated and well-received by students and fostered an awareness of the rewards of listening to patient stories. References: [1] Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-1902. doi:10.1001/jama.286.15.1897; [2] Milota MM, van Thiel GJMW, van Delden JJM. Narrative medicine as a medical education tool: a systematic review. Med Teach. 2019;41(7):802-810. doi:10.1080/0142159X.2019.1584274.

The study aims to describe (1). The role of parents fostering interest in reading elementary school age children through television programs. (2). The positive impact of the TV program "Tau Gak Sih" on the development of reading interest in elementary school age children. The research is objecting to a comprehensive detailed study of the main content, the role of parents in assisting watching television programs to foster interest in reading. The scope of the study includes analysis-based analysis activities, focusing on the role of managing elementary school children's interest in reading by assisting learning. Analysis requires realistic critical thinking to apply conceptualization, so that it uses a historical approach characterized by realistic critical inquiry into the development of a thought. Primary information sources are used as primary data. The technique of collecting data utilizes library research, which is reading various kinds of literature. The analysis was conducted descriptively qualitative, sourced from theoretical reading material, research and not research. The validity of the research can be achieved by utilizing content analysis, in order to analyze the meaning, the role of parents, the function of the family in developing interest in reading elementary school-age children through TV programs. Observation is used as an element to support the construction of the theory. The results of the study include; (1) Parents play an important role in providing assistance in fostering elementary school-age children's interest in reading through television programs. (2) The positive impact of the TV program "Tau Gak Sih" on the development of reading interest in elementary school age children is as a medium of learning, expanding knowledge and motivating reading activities

The article examines the methodological principles of creating educational and creative programs at the third level of higher education in the specialty “Performing Arts”. On the example of the program of the I. K. Karpenko-Kary Kyiv National University of Theater, Cinema and Television, the necessary requirements for the conceptual and methodological foundations of the construction of such programs were identified and considered. The components of such a program aimed at acquiring in-depth knowledge and improving professional training in the field of performing arts are analyzed. It is noted that the quality of the final learning results is ensured through the acquisition of competencies in the field of research, teaching and creative work. The proposed options for filling the program with components that can satisfy the requirements for the preparation of the degree holder at the educational and creative level of higher education and will contribute to the maximum disclosure and realization of his or her creative potential in further professional activity. The obtained conclusions and recommendations can create a methodological base for further improvement of the training system for those who obtain the degree of Doctor of Arts (D.A).

The book, unusual in concept, was published on the occasion of the 100th anniversary of the Soviet and Russian scientist, Doctor of Technical Sciences, Professor Mark Iosifovich Krivosheev (1922-2018), who made an undeniable contribution to the development of TV broadcasting in the world. His merits and inventions are recognized by both domestic and foreign technical experts and international organizations, such as the International Telecommunication Union. The peculiarity of the book is that it is based on the personal notes of the professor, which is of particular value, allowing the reader to understand the point of view of an eyewitness to events at different stages of history. This book is the story of its main author (there are supplementary remarks-explanations in the book) about the difficult path of becoming a TV broadcasting platform and the development of television, which has gone through the stages from infancy to multi-program digital interactive TV broadcasting. It also contains inclusions from the personal life of a scientist, starting from childhood, which focuses attention on the business qualities of a scientist-innovator. The review analyzes the aspects and trends in the development of modern digital television, substantiates character traits that are important for the formation of the personality of a research scientist.

Border residents in Meranti Regency still love Malaysian free to air television broadcasts. The broadcasting regulation stipulates that broadcasters must provide free to air access to foster a love of Indonesian television broadcasts and a spirit of nationalism for all levels of society. However, the reality in the field is inversely proportional. An important point that questioned in this research is how the implementation of broadcasting regulations governing equality of access to information and containers of cultural expression in free to air broadcasts for all Indonesian people, especially in border areas. This study aims to reveal the extent of the application of broadcasting regulations in the border region in the context of free to air broadcasts and cultural expression containers in free to air broadcasts. Social action media studies used as an analytical tool to reveal that access and broadcasting infrastructure are a necessity for reaching viewers. The program of the choice model is another analytical tool in uncovering the motives for selecting free to air broadcasts that are loved by border society. The case study method used to find data from the field of a single case that is the implementation of free to air broadcasting regulations in the Indonesian border region of Malaysia. As a result, broadcasting regulations are considered unsuccessful in the context of free to air in the border regions, and the expression of Malay culture has no place on Indonesian television, which in turn, the Malay cultural preference filled with free to air Malaysian broadcasts. Keyword: Broadcasting, free-to-air, audience, border society, culture.

Therapeutic intervention involving the technique of Relaxation, Mental Images, and Spirituality (RIME) can foster the redefinition of spiritual pain in terminal patients. A training course was developed to instruct health care professionals in its use, and the results were followed up by evaluating reactions of professionals to its use in intervention with patients. Six subjects (a nurse, a doctor, three psychologists, and an alternative therapist), all skilled in palliative care, were invited to take part in the experience. They worked with 11 terminal patients in public hospitals of the cities of Campinas, Piracicaba, and São Paulo, located in Brazil. The theoretical basis for the study involves action research and phenomenology, and the results were analyzed using both qualitative and quantitative methods. The analysis of the experience of the professionals revealed 5 categories and 15 subcategories. The analysis of the nature of spiritual pain revealed 6 categories and 11 subcategories. The administration of RIME revealed statistically significant differences (p< 0.0001), i.e., patients reported a greater level of well-being at the end than at the beginning of sessions, which suggests that RIME led to the redefinition of spiritual pain for these terminal patients. The training program proposed has shown itself to be effective in preparing health care professionals for the use of RIME intervention.

Background. In the modern contemporary, there are obvious demands for accurate interpretations of the worldwide problem, which is medication errors (MEs) due to various serious negative events that effect patient health. Most parts of the world considered health as significant issue for centuries. Recently, investigators have examined the effects of writing physician orders from the nurse’s viewpoint and represent that 100% of ambiguous writing of doctor orders related directly to MEs. Objective. The aim of our work is to investigate the major causes of (MEs) in the Saudi Arabia population from multiple aspects. Methods. An online review gave quantitative information from 450 members. Respondents were heedlessly parceled into two conditions (Yes+, No−) and mentioned to respond to one of two plans of the explanations behind the medical errors. Fourteen determining factors in the predesign have been chosen. Entire data were collected relevant to the study purpose and the content of the questionnaire written suitably to the participants with no ambiguous terms to analyze obtained data accurately using supersaturated plans and regression methods utilizing the SPSS program to decide the real causes of the medical errors. Results. The findings indicated that often failures in the care process can be traced back to poor documentation and a lack or inadequacy of procedures; the limitations of integrated health systems between the doctor and pharmacists, human problems when standards of care, policies, processes, or procedures are not properly or effectively followed, inadequate use of technology in healthcare facilities, and unclear line of prescription from the doctor are factors that contributed to the medical errors. Conclusion. The Saudi Arabian government needs to foster a functional arrangement to examine these reasons for medical errors and make a move. Future investigations could break down the information utilizing edge plans technique.

In the last two years, the COVID-19 pandemic has presented new bioethical challenges for humanity. Cinemeducation uses movies and television series to enhance understanding of complex concepts. The present study assessed the effectiveness of cinemeducation in teaching bioethical issues related to the COVID-19 pandemic to students of health sciences and humanities. Participants were recruited from two classes of fourth-year undergraduate students: those enrolled in a bioethics course in the Human Biology degree program (n=34) and in a course on social transformation in the Humanities degree program (n=29). The two classes watched clips from the TV medical dramas Grey’s Anatomy, The Good Doctor, and Chicago Med in a guided two-hour classroom activity. Participation in the study was voluntary. To measure the activity’s effects on learning, a 10-question multiple-choice questionnaire was administered before and after the activity. To measure students’ satisfaction, a survey about the usefulness of the activity was also administered. A total of 45 out of 63 (71.4%) students completed the questionnaires. Scores in both groups were higher after the activity (p< 0.05); mean improvements were 0.607 (95% CI: 1.16–0.45) for Human Biology students and 3.00 (95% CI: 3.87–2.12) for Humanities students. The improvement was higher in Humanities students (p < 0.05). Students’ satisfaction was high in both groups. The findings imply that cinemeducation can be effective for teaching some complex bioethics concepts in relation to the COVID-19 pandemic.

PurposeHearing loss prevention has always been an important issue for audiologists. The importance of hearing loss prevention education for young musicians is now recognized by the National Association for Music Education as well as the National Association of Schools of Music. Adopt-a-Band is a commercial program designed to foster hearing loss prevention behavior in young musicians.MethodThis study assessed changes in earplug use, measured using self-report surveys, after Adopt-a-Band training. Participants were members of 2 high school marching bands who viewed an informational DVD and reviewed fact sheets. Flat-attenuation earplugs were distributed, and training was provided. In addition, study participants engaged in discussion of hearing loss with a doctor of audiology student.ResultsBefore training, 23% of participants reported they had previously used hearing protection. Immediately after training, 94% of participants reported they planned to use hearing protection at least occasionally. In a final end-of-season survey, earplug use had reliably increased; 62% of participants reported they used earplugs at least occasionally.ConclusionsEarplug use increased, but self-reported behavioral change was not as robust as predicted from self-reported participant intentions. Participant comments regarding factors that influenced their earplug use decisions suggest opportunities to improve training.

Objective To investigate the motivations, challenges and perceptions of the educational environment of emerging researchers in chiropractic. Methods A descriptive web-based survey of higher-degree chiropractic research students was performed between October and November 2013. The survey consisted of open and closed questions and the Dundee Ready Education Environment Measure. Results Twenty-two students currently enrolled in a higher-degree research program participated. Students were most commonly enrolled in a doctor of philosophy program at a part-time rate. Motivations of research were desire to improve the clinical care aspects of chiropractic for the public and belief that chiropractic research is lacking. The greatest challenges were the negative attitudes towards chiropractic, finding enough time to do everything required, and feelings of isolation. The higher-degree research educational environment was perceived to be more positive than negative, with the stimulating nature of research a positive feature. A negative feature of the educational environment was poor undergraduate preparation for higher-degree research. Conclusion This study is the first study to describe higher-degree chiropractic research students. Primary motivations included building research, while challenges included not only negative attitudes toward the chiropractic profession but also negative attitudes toward researchers from within the profession. The higher-degree research educational environment was perceived to be positive. By acknowledging the issues that surround emerging researchers in chiropractic, the profession is better placed to foster academics and build research capacity.

Background Patient involvement in goals of care decision-making has shown to enhance satisfaction, affective-cognitive outcomes, allocative efficiency, and reduce unwarranted clinical variation. However, the involvement of patients in goals of care planning within hospitals remains limited, particularly where mismatches in shared understanding between doctors and patients are present. Aim To identify and critically examine factors influencing goals of care conversations between doctors and patients during acute hospital illness. Design Realist systematic review following the RAMESES standards. A protocol has been published in PROSPERO (CRD42021297410). The review utilised realist synthesis methodology, including a scoping literature search to generate initial theories, theory refinement through stakeholder consultation, and a systematic literature search to support program theory. Data sources Data were collected from Medline, PubMed, Embase, CINAHL, PsychINFO, Scopus databases (1946 to 14 July 2023), citation tracking, and Google Scholar. Open-Grey was utilized to identify relevant grey literature. Studies were selected based on relevance and rigor to support theory development. Results Our analysis included 52 papers, supporting seven context-mechanism-output (CMO) hypotheses. Findings suggest that shared doctor-patient understanding relies on doctors being confident, competent, and personable to foster trusting relationships with patients. Low doctor confidence often leads to avoidance of discussions. Moreover, information provided to patients is often inconsistent, biased, procedure-focused, and lacks personalisation. Acute illness, medical jargon, poor health literacy, and high emotional states further hinder patient understanding. Conclusions Goals of care conversations in hospitals are nuanced and often suboptimal. To improve patient experiences and outcome of care interventions should be personalised and tailored to individual needs, emphasizing effective communication and trusting relationships among patients, families, doctors, and healthcare teams. Inclusion of caregivers and acknowledgment at the service level are crucial for achieving desired outcomes. Implications for policy, research, and clinical practice, including further training and skills development for doctors, are discussed.

Background and context: Cancer is the second most common cause of death in Samoa. Early detection increases the likelihood of successful treatment; however, in Samoa, cancer patients often present late, when treatment options are limited and often reduced to receiving palliative care. Low levels of health literacy in relation to cancer causation, risk factors, and signs and symptoms contribute to poor outcomes for cancer patients in Samoa. Aim: The Vave (Quickly) campaign aimed to increase community awareness about the signs and symptoms of cancer, and promote early detection. Strategy/Tactics: This was a 12-month national social marketing campaign designed to ensure maximum population reach across Samoa. The campaign adopted a multipronged approach with three main components: mass and social media coverage; printed resources; and community education. All components included the campaign messages: early detection; quickly see a doctor; and quickly ring Samoa Cancer Society (SCS). Program/Policy process: The campaign focused on four of the most common cancers in Samoa: stomach, lung, breast, and prostate. Television advertisements and radio scripts were developed for each type of cancer, piloted and broadcast on the main television and radio stations. Printed materials were developed, including brochures, posters and banners. Community educators delivered a total of 29 face-to-face education sessions across Samoa; these sessions prioritized villages, schools and church groups in areas with poor television and radio coverage. Outcomes: The campaign was successful in increasing awareness of cancer signs and symptoms in the community. Approximately 2000 Samoans (over 1% of the population) received the face-to-face education sessions; analysis of pre- and postsession questionnaires showed that the sessions were effective in increasing health literacy around cancer signs and symptoms. In addition, the number of inquiries received by SCS increased significantly as a result of the advertisements, from an average of 18 inquiries per month in the months prior to the implementation of the campaign to 40 inquiries during the campaign. This increase was particularly marked during October (Breast Cancer Awareness Month) when SCS received 112 inquiries. Limited data on patient visits suggests that the campaign resulted in increased numbers of hospital and general practice visits, and is likely to have contributed to the early detection of some cancers. What was learned: · The campaign resulted in an increase in inquiries and requests for check-ups; however, limited availability of medical and screening services must be considered when managing community expectations. · Establishing effective community and professional relationships contributed to the success of the campaign. Formative research and greater involvement of health professionals throughout the campaign would have prevented some implementation issues.

Background. Pakistan is a country with one of the highest burden of tuberculosis (TB) in the world, and therefore, it is imperative to revisit the design of behaviour change interventions in the program. This study was designed to understand and assess the knowledge, awareness, perceptions, and health-seeking behaviour of general and specifically TB-affected population and to determine the presence and level of stigma and discrimination toward TB patients. Methods. A mixed-method study was conducted in district Haripur of the Khyber Pakhtunkhwa province, comprising a household survey, whereby 526 individuals were interviewed, and five focus group discussions with various subgroups including TB patients and health workers and authorities. Study sought an ethical approval, and data of all respondents was kept confidential. Results. Quantitative results show that women were more knowledgeable on symptomatology and spread of TB, and with rising education, awareness on TB improves. The majority of our respondents had the understanding that it is a curable disease, yet some would avoid TB patients. Most of the respondents (both men and women) knew that one must go to a government facility for treatment. Only one-third would speak to doctor first, if they suspect TB-like symptoms. Television was a popular source of information on TB. Qualitative results captured people’s perceptions that TB was related with poverty and was still considered a stigma in the community; hence, patients afflicted feared disclosing the disease. Conclusion. With contextual understanding of communities’ knowledge, attitudes, health-seeking behaviour, and care-seeking patterns, it can be concluded that there is a need to increase the awareness about TB symptoms, mode of transmission, prevention, diagnosis and treatment, and destigmatization of the disease through health education.

Background:Establishing a transition program is important in bridging the gap between pediatric and adult healthcare especially in patients with chronic diseases. The Division of Pediatric Rheumatology of the Philippine General Hospital (PGH) established the Lipat Kalinga Adolescent Transition Clinic (LKATC) to help in the transfer from pediatric to adult healthcare by providing the support and guidance needed through education and reinforcement of self-management skills. This study is an assessment of the effect of the LKATC on the transition readiness of Filipino adolescents with rheumatic diseases at the PGH.Objectives:To assess the effect of the LKATC program on Filipino adolescent patients with rheumatic diseasesMethods:This is a mixed-method study design done at the Philippine General Hospital. A retrospective descriptive before and after study was conducted along with a focus group discussion (FGD). The participants were pediatric rheumatology patients enrolled at the LKATC from May,2018 to April,2019. Comparison of the pre and post University of North Carolina (UNC) TRxANSITION scale (Filipino version) overall score and domains was done and facilitation of an FGD to elicit barriers and facilitating factors for the effective implementation of the LKATC. The FGD used a predefined discussion guide based on literature review and was done by a trained facilitator.Results:We evaluated a total of 17 adolescent patients with rheumatologic diseases. Comparing the pre-intervention and post-intervention test scores, statistically significant increases were noted in several domains. Health transitional skills of these adolescents were noted to improve in terms of total score, medication, nutrition, self-management, informed reproduction, trade and school issues, insurance issues, and new health providers. There was no significant improvement in the type of illness, adherence and ongoing support.Four patients who were enrolled at the LKATC and who attended at least 5 sessions participated in the FGD. The barrier themes elicited were 1. Expectation and beliefs regarding adult healthcare, 2. Different doctor-patient relationship, 3. Logistical problems. The facilitating themes elicited were 1. Familiarization, 2. Peer support, 3. Communication.Conclusion:This study showed the effects of an adolescent transition clinic program in Filipino adolescent with rheumatic disease. Significant increase in the overall UNC TRxANSITION score as well as majority of the scores per domains were seen. Barriers and facilitating factors affecting the transition process elicited during a focus group discussion were also presented. This study provided baseline data on the importance of establishing an adolescent transition clinic for patients with chronic disease in the local setting.References:[1]Foster, H. et al. EULAR/PReS standards and recommendations for the transitional care of young people with juvenile-onset rheumatic diseases. Ann Rheum Dis 2016;0:1-8.[2]Alfiler, CA, Llanto, EA et al. Adolescent Pediatric Kidney Patients Transitioned to Adult Health Care Services through the Philippine General Hospital Transition Program. Acta Medica Philipina Vol 46 No. 4 2012-Vol 47 No. 1 2013Disclosure of Interests:None declared

Aim/Purpose: In response to widespread efforts to increase the size and diversity of the biomedical-research workforce in the U.S., a large-scale qualitative study was conducted to examine current and former students’ training experiences in MD (Doctor of Medicine), PhD (Doctor of Philosophy), and MD-PhD dual-degree programs. In this paper, we aimed to describe the experiences of a subset of study participants who had dropped out their MD-PhD dual-degree training program, the reasons they entered the MD-PhD program, as well as their reasons for discontinuing their training for the MD-PhD. Background: To our knowledge, the U.S. has the longest history of MD-PhD dual-degree training programs dating back to the 1950s and produces the largest number of MD-PhD graduates in the world. Integrated dual-degree MD-PhD programs are offered at more than 90 medical schools in the U.S., and historically have included three phases – preclinical, PhD-research, and clinical training, all during medical-school training. On average, it takes eight years of training to complete requirements for the MD-PhD dual-degree. MD-PhD students have unique training experiences, different from MD-only or PhD-only students. Not all MD-PhD students complete their training, at a cost to funding agencies, schools, and students themselves. Methodology: We purposefully sampled from 97 U.S. schools with doctoral programs, posting advertisements for recruitment of participants who were engaged in or had completed PhD, MD, and MD-PhD training. Between 2011 and 2013, semi-structured, one-on-one phone interviews were conducted with 217 participants. Using a phenomenological approach and inductive, thematic analysis, we examined students’ reasons for entering the MD-PhD dual-degree program, when they decided to leave, and their reasons for leaving MD-PhD training. Contribution: Study findings offer new insights into MD-PhD students’ reasons for leaving the program, beyond what is known about program attrition based on retrospective analysis of existing national data, as little is known about students’ actual reasons for attrition. By more deeply exploring students’ reasons for attrition, programs can find ways to improve MD-PhD students’ training experiences and boost their retention in these dual-degree programs to completion, which will, in turn, foster expansion of the biomedical-research-workforce capacity. Findings: Seven participants in the larger study reported during their interview that they left their MD-PhD programs before finishing, and these were the only participants who reported leaving their doctoral training. At the time of interview, two participants had completed the MD and were academic-medicine faculty, four were completing medical school, and one dropped out of medicine to complete a PhD in Education. Participants reported enrolling in MD-PhD programs to work in both clinical practice and research. Very positive college research experiences, mentorship, and personal reasons also played important roles in participants’ decisions to pursue the dual MD-PhD degree. However, once in the program, positive mentorship and other opportunities that they experienced during or after college, which initially drew candidates to the program was found lacking. Four themes emerged as reasons for leaving the MD-PhD program: (1) declining interest in research, (2) isolation and lack of social integration during the different training phases, (3) suboptimal PhD-advising experiences, and (4) unforeseen obstacles to completing PhD research requirements, such as loss of funding. Recommendations for Practitioners: Though limited by a small sample size, findings highlight the need for better integrated institutional and programmatic supports for MD-PhD students, especially during PhD training. Recommendation for Researchers: Researchers should continue to explore if other programmatic aspects of MD-PhD training (other than challenges experienced during PhD training, as discussed in this paper) are particularly problematic and pose challenges to the successful completion of the program. Impact on Society: The MD-PhD workforce comprises a small, but highly trained cadre of physician-scientists with the expertise to conduct clinical and/or basic science research aimed at improving patient care and developing new diagnostic tools and therapies. Although MD-PhD graduates comprise a small proportion of all MD graduates in the U.S. and globally, about half of all MD-trained physician-scientists in the U.S. federally funded biomedical-research workforce are MD-PhD-trained physicians. Training is extensive and rigorous. Improving experiences during the PhD-training phase could help reduce MD-PhD program attrition, as attrition results in substantial financial cost to federal and private funding agencies and to medical schools that fund MD-PhD programs in the U.S. and other countries. Future Research: Future research could examine, in greater depth, how communications among students, faculty and administrators in various settings, such as classrooms, research labs, and clinics, might help MD-PhD students become more fully integrated into each new program phase and continue in the program to completion. Future research could also examine experiences of MD-PhD students from groups underrepresented in medicine and the biomedical-research workforce (e.g., first-generation college graduates, women, and racial/ethnic minorities), which might serve to inform interventions to increase the numbers of applicants to MD-PhD programs and help reverse the steady decline in the physician-scientist workforce over the past several decades.

This report was made at the Doctor Honoris Causa conferred to Prof. Leonidas Donskis by Valahia University of Târgoviște on November 6th, 2014. The editors express their gratitudeto Vlad-Gabriel Ghiorghiu, a CoolPeace graduate, for the admirable translation of this report. The publication of this report is supported by EEA Grants, contract no 4/22.07.2014. Currently a professor of advanced studies and academic development at the ISM University of Management and Economics of Kaunas and Vilnius, Lithuania, and a former member of the European Parliament, Leonidas Donskis was born on the 13th of August 1962 in Klaipėda, Lithuania. From 2005 to 2009 he served as dean of the Faculty of Political Science and Diplomacy at Vytautas Magnus University of Kaunas, Lithuania. As a docent, visiting and associate professor, he also taught at the University of Helsinki, Finland, in the field of social and moral philosophy, at the University of Tallinn, Estonia, in the field of philosophy and theory of culture, as well as universities from the United States (Dickinson College, Pennsylvania and Montevallo University, Alabama) in the field of cultural studies and universities from England, Italy and Hungary in similar fields of endeavor. Alongside his scholarly career stands his remarkable contribution to the field of the mass-media, both as a producer and moderator of cultural programs for the Lithuanian Television or as editor for the print media (The Baltic Times, The Ukrainian Week etc). The academic bettering carried out in countries like Lithuania and Finland spawned his encyclopedic character and determined the ramification of his intellectual interests. His bachelor’s degree in philosophy and theater, received from the Lithuanian State Conservatoire (presently the “Lithuanian Academy of Music and Theatre”) in 1985 was followed by a master’s degree program in philosophical studies at the University of Vilnius (1987). From the same university he took his first doctorate in philosophy and the humanities, with a thesis about the culture in crisis and the philosophy of culture in the views of O. Spengler, A. J. Toynbee and L. Mumford (1990). This was soon to be followed by a second doctorate, received from the University of Helsinki, with a thesis dwelling on the relation between ideology and utopia, moral imagination and cultural criticism in the 20th century (1999).

‘The doctors of tomorrow will be applying knowledge and deploying skills which are at present unforeseen’. This was written by General Medical Council , UK in “Tomorrow’s Doctor” 1993,(General Medical Council, 1993), but this still holds true. We as health care providers strive to provide the best of care to our patients and perhaps doing a good job. You may object to this “perhaps “as obviously at a glance the health care appears optimal. But we do not know that underneath this poise and calm sea are deadly sharks that gulp and bite our results. Statistically speaking, there is one in eleven million risks of being bitten by a shark. In comparison, the risk of patient death occurring due to a preventable medical accident, while receiving health care, is estimated to be one in three hundred. It is obvious that you are safer in diving in the ocean than receiving treatment at a health care facility. Yet it is preventable. This preventable medical accident is the hidden shark of our clinical practice that bites our results without us even knowing about it. Hippocrates defined patient safety as primum no nocere, or “First, do no harm.” Yet we discovered it quite recently. A television program by the name of ” Deep Sleep “ aired in April 1983 first shocked the public that six thousand patients die due to anesthesia-related deaths. In 1983, the Harvard Medical School and the British Royal Society of Medicine jointly sponsored a symposium on anesthesia, deaths, and injuries. They also agreed to share statistics and to conduct studies for all anesthesia accidents. In 1984, the American Society of Anesthesiologists (ASA) had established the Anesthesia Patient Safety Foundation (APSF). The foundation marked the first use of the term “patient safety” in the name of a professional reviewing organization. The Australian Patient Safety Foundation was founded in 1989 for anesthesia error monitoring. Both organizations were soon expanded, as the magnitude of the medical error crisis became known. The studies expanded to all specialties, areas, and actual impact was measured. It is now estimated that that healthcare errors impact one in every ten patients around the world, the World Health Organization calls patient safety an endemic concern. Alarming, isn’t it? Yes, it is quite an alarming situation and it is the time that we all must blow the whistle to this global as well as regional problem. We are at a very initial stage where most of us are not even aware of its serious concerns. The waters are infested with sharks, and we must know and learn how to tackle them. The errors typically include surgical, diagnostic, medication, devices and equipment, and systems failures, infections, falls, and healthcare technology. Wrong or missed diagnosis and side effects of drugs are more common. No area of health care delivery is exempt, but they occur more so in an emergency room and outpatient clinic. (Bari, Khan, & Rathore, 2016) Errors are classified as two types: 1. Errors of omission occur because of actions not taken. Examples are not putting a strap to a patient. 2. Errors of the commission occur because of the wrong action taken. Examples include administering a medication to which a patient has a known allergy. You must be wondering why I chose this in a medical education journal. First and foremost, it is one of the serious international health concerns in the current era. Globally, almost a million patients die each year along with the cost associated with medication errors of about $42 billion USD annually. Secondly, the key to the solution lies with medical educationists. By now, you must be wondering how medical educationists could solve the predicament. Well! The solution lies in developing skills like communication, organization, teamwork, leadership, and decision-making. Not just the skills but also patient safety attitudes have to be adapted along with developing a “safety culture” at the workplace (Ayub & Khan, 2018). Our doctors of future and health care centers will only be safe if the safety is taught and assessed, at every level of learning and teaching. The culture of patient safety is created by identifying errors, developing systems based on newer technologies to recognize and correct errors. A broad range of safety culture properties can be organized into multiple subcultures like leadership, teamwork, evidence-based patient care, communication, learning from errors, identifying systems errors, and providing patient-centered care. Currently, the issue is remotely addressed in learning and teaching at both graduate and postgraduate levels. It is imperative that medical educationist should play their role by not only learning but also teaching all the necessary skills required to develop a safe environment for patients. The waters are full of sharks, and we must take protective measures. Stay safe References Ayub, A., & Khan, R. A. 2018. Learning to cure with care: Awareness of faculty and medical students about students’ roles related to patient safety. J. Pak. Med. Assoc., 68(9). Bari, A., Khan, R. A., & Rathore, A. W. 2016. Medical errors; causes, consequences, emotional response and resulting behavioral change. Pakistan J. Med. Sci., 32(3) doi:10.12669/ pjms.323.9701. General Medical Council, U.K. (1993). Tomorrow’s doctors: Recommendations on undergraduate medical education. London.

Abstract This special issue asks the question of what new digital technologies bring to the re-telling of old stories. In our contribution, we discuss how the practice of TV cloning on transnational digital streaming platforms has affected almost a decade of remixing and reformatting the Medea myth. In 2015, British playwright Mike Bartlett, best known for his work in theatre, adapted Medea to British television. The resulting BBC production Doctor Foster was a hit and spawned a second series in 2017. Subsequently Doctor Foster became a global phenomenon as it was remade in a variety of surprisingly diverse cultural milieus. The localized adaptations of Doctor Foster are cases of franchise diversification and expansion that gave new traction to the tradition of ‘programme adaptation’ (Keane/Moran) and has been dubbed ‘TV formatting’ (Moran/Malbon, Miller) or ‘TV cloning’ (Fung/Zhang). They are not a new phenomenon, as early 21st century precursors predate the world of television streaming or what Amanda Lotz has called ‘internet-distributed television’, but the diversified world of platform TV seems ideally suited to the practice of TV cloning. According to Michael Keane and Albert Moran (6) the format is ‘the total package of information and know-how that increases the adaptability of a program in another place and time’. Possession of the format enables producers to grant licenses and enforce copyright. The context for this study that seeks to address both the emerging textualities and practices of these digitally transformed TV industries is the fluid redistribution of television consumption zones across the planet.

This article examines the representation of the COVID-19 global public health crisis on U.S. network television medical dramas. Programs featuring healthcare professionals like Chicago Med (NBC, 2015-present), The Good Doctor (ABC, 2017–2024), and New Amsterdam (NBC, 2018–2023) depicted the devastation of the pandemic and the plight of the frontline healthcare community to viewers at home through the fictional hospital. In particular, Grey’s Anatomy (ABC, 2005–present) produced a “very special season” dedicated to portraying COVID’s toil. I argue that the primetime doctor show attempted to lessen the pain of COVID’s impact by presenting its audience-as-patient with a way to manage their emotions around loss through narrative catharsis. The program adheres to a logic of alleviation in its care work for viewers. Such a tele-therapeutic strategy of engagement on the long-running Grey’s Anatomy, amidst mass suffering and death, also served to revive the series as compelling broadcast television in the streaming era.

The relationship between human beings and technology has been a regular concern of the television series, Doctor Who. Though its titular hero moves through space-time by means of advanced technology and he is by his own admission a technological genius and Doctor 'of everything really', the program nevertheless consistently maps the unease that attends the interaction of humans and the technology - whether through the human characters' horror at the abuse of technology and its power or through characters who incorporate this interaction.The trope of the cyborg, the human-machine hybrid that articulates many contemporary fears (and desires) about the intrusion of technology on the 'human' is enacted and embodied in Doctor Who by the Daleks and the Cybermen - long-term enemies of the Doctor. In the recent new series (2005-2009) featuring Christopher Eccleston and David Tennant both Daleks and Cybermen have returned, to enact contemporary concerns about new technologies. This paper explores the recent Dalek double-episode, "Daleks in Manhattan" and "Evolution of the Daleks" (2007) for its representation of current human-technology relationships.

Objective Despite the use of service learning in other health care education programs, little is published about its use in doctor of chiropractic programs. Since 2017, the public health course at our institution has included a service-learning assignment in which students volunteer for nonprofit organizations and write an essay about their experience. The objective of this study was to assess the effects of the assignment on students' self-reported public health knowledge and attitudes. Methods Between April 2017 and June 2018, 56 essays were collected from students who volunteered at a nonprofit organization focused on 3 categories: youth, the environment, or poverty. Each essay was deidentified and assigned random 4-digit-number file names. Ten files were randomly selected from each of the 3 categories for qualitative thematic analysis using deductive and inductive coding. Results Student essays demonstrated competency in public health concepts, including organizational systems, levels of prevention, and the social ecological model. In addition, a majority of the students went beyond discussing knowledge gained from this assignment and described the impact of their experience on their personal growth. Conclusion This study demonstrates that students respond favorably to a service-learning assignment that addresses public health competencies and may foster personal and professional development.

Since the 2000s, the television industry in Turkey has emerged as a transnational business and as one of the largest TV program exporters worldwide. However, Turkish television is still largely national in its production practices and content, and thus, highly vulnerable to the domestic political landscape and media regulations of the government. In the last two decades, rather than endorsing the independent growth of this emerging industry in the international markets, the Turkish government has erected barriers by tightening censorship and passing new regulations to control national television and its content production. The AKP government deployed various state apparatuses, including Turkey's public broadcasting channel (TRT), English language news channel (TRT World), and the regulatory agency Radio and Television Supreme Council (RTÜK) to foster the type of television content that can ideologically serve the AKP's conservative and neo-Ottomanist agendas. Drawing on the political economy of media and through critical analysis, this paper analyzes how these state mechanisms are used to instrumentalize TV exports and media institutions in service of President Erdoğan's cultural, economic, and foreign policy agendas within the country and abroad. By investigating the tension between the state's ideological project and the regional, transnational, and global mediasphere, our work sheds light on how the implementation of the government's new media and cultural policies, top-down directives and pressures from the state and government on both the TV industry and its audience, and South-to-South cultural flows have shaped the Turkish TV industry and its content in the last two decades.

Abstract In 2002, the Institute of Medicine’s recommendations emphasized diversifying the health care workforce to reduce racial and ethnic health disparities. Despite these efforts, the physical therapist profession remains predominantly White. The College of Saint Mary (CSM) Doctor of Physical Therapy program employs deliberate strategies through 2 committees, faculty search and admissions, to foster diversity in both faculty and student populations. The CSM DPT Program Faculty Search Committee, in collaboration with the CSM Human Resource Department, devised a comprehensive 3-phase recruitment process aimed at attracting qualified candidates from diverse backgrounds. Through purposeful mission-driven and equity-focused strategies, this approach has yielded a faculty body characterized by diversity, with 80% of faculty members self-identifying as belonging to historically excluded groups. Similarly, the Admissions Committee has adopted proactive measures to ensure a diverse student body. By implementing a holistic admissions process recommended by the Association of American Medical Colleges, including evaluating prerequisite courses and eliminating the Graduate Record Examination requirement, the committee has facilitated more equitable access to the program. Virtual interviews and thorough candidate assessments are conducted to mitigate potential biases in the selection process. As a result, these efforts have allowed us to maintain diverse cohorts, with 20–30% of our student body identifying as members of historically excluded groups. Impact. Developing and sustaining a physical therapist workforce that reflects the communities it serves necessitates purposeful, mission-driven, and equitable strategies. These strategies aim to broaden the diversity of both faculty and student populations. Through such initiatives, we aim to foster an inclusive environment that reflects our society’s richness, enabling us to better understand society’s complex needs and mitigate health disparities.

Abstract Background Dietary practices are acquired in the family context and in turn can affect the health of family members, especially the nutritional status of children. The objective of this study was to determine the relationship between nutritional status and feeding practices in children from foster families served by the SOS Children's Villages program in Cartagena, Colombia. Methods The study had a cross-sectional design. Through a non-probabilistic purposive sampling, 139 children from 0 to 5 years of age from the SOS Children's Villages Cartagena program were involved. The sociodemographic background of the participants was recorded and the nutritional status of the children was evaluated through anthropometric and biochemical measurements. Dietary practices were measured by means of a standardized questionnaire. Analyses were performed with Poisson regression models with robust variance. These regression models provided prevalence ratios (PR) with their respective 95% confidence intervals (95%CI). Results Among dietary practices, it was observed that most families eat together at home (63.3%), watch television when they eat (55.4%), and have dietary norms (80.6%). Consumption of plant foods was predominantly high, especially vegetables (86.3%), fruits (92.1%), cereals (84.9%), root vegetables, and bananas (93.5%). Consumption < 4 times/week of soft drinks and industrialized juices increases 14.3 times the probability of low weight-for-height in the study population compared to the group that does not consume them. On the other hand, watching television while eating (PR: 2.82, 95%CI 1.32—4.69) and consumption of sweet snacks (PR: 2.24, 95%CI 1.03—4.87) increased the probability of low height-for-age; while having eaten norms at home decreased the probability of low height-for-age in the study population by 50%. Conclusion It is necessary to develop and implement interventions such as preventive measures and early diagnosis of inappropriate feeding behaviors to ensure adequate nutritional status among children under 5 years of age.

This article discusses the role of the technologies that have been utilized to advance distance teaching and learning by the National Distance Education University (Universidad Nacional de Educación a Distancia -- UNED) of Spain. Following a description of UNED's historical development and organizational structure, UNED's experience with various educational media is discussed. Printed teaching materials, in the form of didactic units, were one of the first methods to be utilized when UNED began its operations in 1972. In turn, the role of radio and audio recordings, television and video recordings, telephone, videoconferencing, computer systems and computer-mediated communications are also described. UNED's pioneering projects, including the virtual classroom, virtual campus and a program for the physically handicapped, are also detailed. Recent experiments include providing access to radio and television programs on the Internet and adoption of WebCT. On the horizon for UNED are portals for cellular phones using WAP technology and gearing up for multiple applications in accordance with Universal Mobile Telecommunications Technology (UMTS). Lorenzo García Aretio is a Doctor in Educational Science, Professor of Education, and UNESCO Chair in Distance Education at the National Distance Education University (UNED) of Spain. He has also been Director of the University Institute of Distance Education at UNED. As a writer and editor, Lorenzo García Aretio has published 15 books on distance education. He has also written more than 70 articles and chapters for various distance education journals and books.

The need for effective leadership by physicians is clear, yet the design/delivery of curricula, and assessment of leadership competencies, in Undergraduate Medical Education (UGME) continues to need work. In reappraising their UGME assessment strategies, the Medical Council of Canada (MCC) invited position papers across diverse lenses, including the CanMEDS Intrinsic Roles. This article is foundational work derived from the report on leadership assessment to the MCC. Using Kern’s Model of Curriculum development as a guide, we reviewed the landscape of Canadian UGME leadership education through an environmental scan of the published and grey literature, Canadian leadership frameworks and resources, and consultation with learner and faculty leadership. Leadership education across programs was highly variable and learners were often unaware of available opportunities. In response, we have suggested processes for curricular development, including strategies for key content, teaching and assessment, and program evaluation considerations. Leadership education cannot remain another checkbox on a list of UGME experiences. Such training necessitates focused attention and investment to foster ongoing identity formation toward becoming a good doctor.

AbstractIntroductionThe transition from medical student to first‐year doctor is notoriously difficult, yielding a high rate of transition failure, burn‐out and mental health deterioration. Doctors in this cohort experience unique challenges during this time, which manifest through performance gaps, issues of professional identity, new occupational pressures, and cultural expectations. Mentoring programs are commonly utilised in the medical profession to foster personal and professional development and improve psychosocial well‐being and career satisfaction. However, there exist no systematic reviews examining the use of mentorship specifically for the first‐year doctor cohort, given the unique transition challenges faced by this vulnerable group.PurposeDue to their transition difficulties, evaluate the research on mentorship specifically for first‐year doctors, and identify the emerging themes that can inform the benefits to this group, the barriers that impede program implementation and the facilitators that contribute to successful mentorship programs for this cohort.Materials and MethodsThe PEO (population, exposure outcome) framework was adopted to develop the research inquiry, after which, a systematic review was conducted, adhering to PRISMA guidelines. The search strategy was conducted with assistance from an experienced university librarian. Screening and selection were completed independently against inclusion/exclusion criteria, by two reviewers. The methodological quality of included studies was assessed using Joanna Briggs critical appraisal instruments. Data sources used included Web of Science Medline, Ebsco Cinahl Plus, Scopus, Web of Science Core Collection and Ovid Journals. Search parameters were restricted to English language and peer‐reviewed; date range was unobstructed up to 26 August 2022.ResultsA total of 4137 articles were retrieved, with 13 considered to have met full inclusion criteria. An integrative review synthesis identified three major themes; benefits of mentoring for first‐year doctors, intrinsic and extrinsic barriers to mentoring programs and facilitating factors that improve successful program implementation.ConclusionFirst‐year doctors report untenable and highly strenuous working conditions, that result in poor mental health and high attrition rates. Formalised, near‐peer, tier mosaic mentoring programs provide significant psychosocial and career benefits to this cohort specifically, bridge the training gap from medical student to first‐year doctor and ameliorate patterns of intergenerational bullying, hierarchy and emotional inhibition. However, mentorship is inextricably interrelated to societal–cultural considerations of identity. Mentorship alone cannot overcome endemic cultural challenges within medicine without broader systemic change; however, programs are a valuable option towards positive support for first‐year doctors.

Our story on the federal government's exclusion policy banning formerly addicted doctors and nurses from billing Medicare or Medicaid for 5 years even after they have been abstinent for years—and in one case, the conviction was expunged—completed drug court and treatment, have their licenses back, are in good standing with their medical boards and are practicing medicine (see “Case studies: Formerly addicted doctor and nurse can't bill Medicare or Medicaid,” ADAW, Aug. 14; https://onlinelibrary.wiley.com/doi/10.1002/adaw.33862) caught the eye of a television news program in Albany, New York. The ADAW editor was interviewed for that program on the story, and on the “unfair and punitive” policy, in the words of Peter Grinspoon, M.D., who was not a victim of the policy but who himself had been addicted to prescription opioids. Health care providers can easily obtain prescription opioids, of course, but if they do not obtain them legally, such as taking a medication meant for a patient or asking someone else to fill prescriptions for them, that is a felony. Also on the show was a nurse who fell victim to the policy. For a link to the 14‐minute news show, go to https://spectrumlocalnews.com/nys/central‐ny/politics/2023/08/21/formerly‐addicted‐doctors‐and‐nurses‐cannot‐bill‐medicare‐or‐medicaid#. As a reporter used to asking questions myself, I found the experience stressful but was grateful for such an intelligent and well‐informed interviewer.

Abstract Background Community Health Representatives (CHRs) overcome health disparities in Native communities by delivering home care, health education, and community health promotion. The Navajo CHR Program partners with the non-profit Community Outreach and Patient Empowerment (COPE), to provide home-based outreach to Navajo clients living with diabetes. COPE has created an intervention (COPE intervention) focusing on multiple levels of improved care including trainings for CHRs on Motivational Interviewing and providing CHRs with culturally-appropriate education materials. The objective of this research is to understand the participant perspective of the CHR-COPE collaborative outreach through exploring patient-reported outcomes (PROs) of clients who consent to receiving the COPE intervention (COPE clients) using a qualitative methods evaluation. Methods Seven COPE clients were selected to participate in semi-structured interviews one year after finishing COPE to explore their perspective and experiences. Qualitative interviews were recorded, transcribed, and coded to identify themes. Results Clients revealed that health education delivered by CHRs facilitated lifestyle changes by helping them understand key health indicators and setting achievable goals through the use of accessible material and encouragement. Clients felt comfortable with CHRs who respected traditional practices and made regular visits. Clients also appreciated when CHRs educated their family members, who in turn were better able to support the client in their health management. Finally, CHRs who implemented the COPE intervention helped patients who were unable to regularly see a primary care doctor for critical care and support in their disease management. Conclusion The COPE-CHR collaboration facilitated trusting client-CHR relationships and allowed clients to better understand their diagnoses. Further investment in materials that respect traditional practices and aim to educate clients’ families may foster these relationships and improve health outcomes. Trial registration clinicaltrials.gov: NCT03326206. Registered 9/26/2017 (retrospectively registered).

Abstract Refugee women are at increased risk to develop perinatal mental health problems, including postpartum depression. The fact that refugee and immigrant women suffering PPD are more likely to be exposed to poverty, lack of social support, or restricted working opportunities suggest that a comprehensive approach that addresses the broader social determinants of health is suited to effectively support their perinatal mental health needs. However, public health programs with such a comprehensive approach are scarce in most European countries. We will present qualitative findings from ‘Health nurses strengthen integration', a universal home visiting program aimed to strengthen the integration of refugee families in Denmark. The program includes a minimum of five 2-h meetings including a mind-mapping of families' psychosocial needs, a focus on parenting in a new culture, and support to connect with social and health services. Nurses are trained in cultural competencies and are provided with interpreters. We conducted 3 focus groups (n = 11) and 2 interviews with health visitors (HV) and 9 interviews with refugee mothers to identify what aspects of a comprehensive approach that foster families' integration can support the mental well-being of refugee mothers after birth. Using thematic network analysis we found how the structure, extra time, and training in cultural competence facilitated HV to use critical self-reflection and cultural sensitivity, use respectful curiosity, create a safe space for sharing, and ‘hand-hold' families in interactions with other services. These practices permitted HV understand the complex needs of families, build trust, and facilitate interactions with others services. Interviews with families illustrated how 1) feeling that someone cared ‘like family', 2) and build-bridging with services (doctor, school, job center) reduced families daily stress. Using the family stress and adaptation theory we will discuss program and policy implications.

PURPOSE Collecting patient-reported outcomes (PROs) can improve symptom control and quality of life, enhance doctor-patient communication, and reduce acute care needs for patients with cancer. Digital solutions facilitate PRO collection, but without robust electronic health record (EHR) integration, effective deployment can be hampered by low patient and clinician engagement and high development and deployment costs. The important components of digital PRO platforms have been defined, but procedures for implementing integrated solutions are not readily available. METHODS As part of the NCI's IMPACT consortium, six health care systems partnered with Epic to develop an EHR-integrated, PRO-based electronic symptom management program (eSyM) to optimize postoperative recovery and well-being during chemotherapy. The agile development process incorporated user-centered design principles that required engagement from patients, clinicians, and health care systems. Whenever possible, the system used validated content from the public domain and took advantage of existing EHR capabilities to automate processes. RESULTS eSyM includes symptom surveys on the basis of the PRO-Common Terminology Criteria for Adverse Events (PRO-CTCAE) plus two global wellness questions; reminders and symptom self-management tip sheets for patients; alerts and symptom reports for clinicians; and population management dashboards. EHR dependencies include a secure Health Insurance Portability and Accountability Act-compliant patient portal; diagnosis, procedure and chemotherapy treatment plan data; registries that identify and track target populations; and the ability to create reminders, alerts, reports, dashboards, and charting shortcuts. CONCLUSION eSyM incorporates validated content and leverages existing EHR capabilities. Build challenges include the innate technical limitations of the EHR, the constrained availability of site technical resources, and sites' heterogenous EHR configurations and policies. Integration of PRO-based symptom management programs into the EHR could help overcome adoption barriers, consolidate clinical workflows, and foster scalability and sustainability. We intend to make eSyM available to all Epic users.

ABSTRACT The objective of this research is to give understanding and clear explanation about teaching students’ listening skill by English video. Commonly, teaching listening through tape recorder, but in this research teacher shows different way, video is collaboration between pictures and sound components, and it contains a recording of a movie or television program. Students can be able to know the activity or a topic being discussion through visual aid and knowing the pictures expression clearly, this way can help students to get clear information both pronunciations and expression. Grade VIII of SMPN 15 Tangerang with total number is 20 students and 10 English teachersas the subject of the research. Qualitative descriptive method is applied in this research to explain teaching process through video clearly, however, literature and questionnaere with close answer form is given to get the data. The result of this research are: firstly, teaching listening skill through video can be used by the teacher to make a listening class is more enjoyable and understandable, because audio visual aid can cover students various learning style, finally at the end of teaching and listening process the objectives of study can be gained. Secondly; teaching listening through video is very useful way to encourage and foster students’ listening skill and their interest. Keywords: Using Video, Listening skill, teaching listening

Stroke is fourth leading cause of death and primary contributor to adult disability in US. Mortality has declined in past 10 years, but prevalence has increased; indicating public risk factor education should be a higher priority. Education is especially important for high-risk individuals Methods: this project assessed knowledge and motivation for behavioral changes in African American females (AAF) >18 years of age before/after a presentation regarding stroke risk factors. A community-based program utilizing video and group discussions was developed using AHA/ASA/NSA resources. A post intervention tool included demographic information and participants’ knowledge regarding stroke symptoms/risk factors. Results are used to plan future education programs Results: fifty-one AAF attended a presentation and completed a survey. Participants were divided into three groups for analysis: 18-35 yo, young; 36-55 yo, middle-aged; and 56+ yo, older. There were 12(24%) young participants, 19 (37.2 %)middle-aged participants, and 20 (39.2%) were older. Prior to educational sessions, participants reported having learned about stroke primarily from television, 28 (55%); doctor, 28 (55%); and family, 25 (50%). Participants identified stroke risk factors as hypertension, 16 (31%); smoking, 10 (20%); obesity, 10 (20%); diabetes, 6 (12%); atrial fibrillation, 3 (6%); and hyperlipidemia, 2 (4%). Participants plan to reduce risk factors through exercise, 17 (33%); diet,11 (22%); and medications, 9 (18%). Forty-four (86%) of participants would call 911 for suspected stroke. The FAST acronym was used to educate participants on signs/symptoms of stroke. The post education survey showed majority of participants were able to name at least one/three signs for stroke, including facial droop, 31 (61%); arm/leg weakness, 28 (55%); and speech changes, 28 (55%). Conclusion: participant responses support literature indicating multiple sources of information are necessary to increase/improve public awareness of stroke risk factors/symptoms. However, ongoing education needed for public to retain knowledge of stroke. Considering cultural differences in populations when designing stroke educational programs is important to utilize the most effective media.

Blaise Pascal once offered the following advice to those perennially worried about knowing fact from fiction: “how few things can be demonstrated! Proofs only convince the mind; custom provides the strongest and most firmly held proofs” (148). The concern about whether or not God existed was for Pascal an unnecessary anxiety: the question couldn’t be answered by human knowledge, and so ultimately one just had to “wager” on whatever stood to be most beneficial, act as if this chosen answer was true, and the mind would eventually fall into line. For Pascal, if one stood to gain from believing in the truth of an idea then the great problems of epistemology could be reduced to a relatively simple and pragmatic calculation of benefit. Doubt, suspicion, and all the attendant epistemological worries would only count as wasted time.It might at first seem surprising that this somewhat antiquated idea of Pascal’s, conceived in seventeenth-century France, appears at the core of a novel by a writer considered to be the quintessential “modern” author, David Foster Wallace. But consider the following advice offered to a recovering drug addict in Wallace’s 1996 novelInfinite Jest. To reap the benefits of the AA program, Don Gately, one of the central characters of the novel, is told by resident counsellor Gene M to imagine he is holding a box of Betty Crocker Cake Mix. The box of cake mix represents Boston AA. Gately is advised that the “box came with directions on the side any eight-year-old could read”: Gene M. said all Gately had to do was for fuck’s sake give himself a break and relax and for once shut up and just follow the directions on the side of the fucking box. It didn’t matter one fuckola whether Gately like believed a cake would result, or whether he understood the like fucking baking-chemistry of howa cake would result: if he just followed the motherfucking directions, and had sense enough to get help from slightly more experienced bakers to keep from fucking the directions up if he got confused somehow, but basically the point was if he just followed the childish directions, a cake would result. He’d have his cake. (467) This advice indeed seems lifted from Pascal almost verbatim (plus or minus a few turns of phrase, of course):Learn from those who have been bound like you, and who now wager all they have. They are people who know the road you want to follow and have been cured of the affliction of which you want to be cured. Follow the way by which they began ... (Pascal 156).While the Pascalian influence on Wallace’s work is perhaps interesting in its own right, and there are certainly more extensive and capable analyses of it to be done than mine, I invoke it here to highlight a particular emphasis in Wallace’s work that I think exceeds the framework through which it is usually understood. Wallace’s fiction is commonly considered an attack on irony, being supposedly at the vanguard of a movement in recent American literature that Adam Kelly, in an illuminating analysis, has called the “New Sincerity” (131). But before anything else irony is a particular trope of understanding, a way of situating oneself in regards to an object of knowledge, and so Wallace’s work needs not only to be understood in terms of what a culture considers unhip, trite, and sentimental, but how it comes to decide upon those things at all, how it chooses to understand its reality. Inspired by the Pascalian influence apparent in Wallace’s portrayal of the Alcoholics Anonymous program, I intend to shift the focus away from issues of irony and sincerity and instead consider the importance of the epistemological tropes of suspicion and trust in reading Infinite Jest. More than anything else Wallace’s depiction of the AA program tells us he is interested, like Pascal, in the existential implications of suspicion, in what might be lost in following doubt to its most “radical” conclusions. I SuspicionIt is fruitful to view Western intellectual practice as exhibiting suspicious tendencies. From Descartes’s “hyperbolic doubt,” the “hermeneutics of suspicion” that Ricœur and Foucault see coming out of the legacy of Marx, Nietzsche, and Freud, to the endless “paranoia of the postmodern” that typifies recent academic trends (Bywater 79), the refusal to trust the veracity of surfaces has been a driving force in post-Enlightenment thought, becoming largely inextricable from how we understand the world. As a mode of critique, suspicion has a particular anxiety about the way fiction masquerades as truth. When a suspicious mind reads a given object, be it an advertisement, a novel, a film, a supermarket, or an egg carton, it most often proceeds by first separating the text into what Paul Ricœur calls an “architecture of meaning” (18), defining those elements it considers fictive and those it considers truer, more essential, in order to locate what it considers “the intentional structure of double meaning” (Ricœur 9). Beneath the fictive surface of a novel, for example, it might find hidden the “truer” forces of social repression and patriarchy. Behind the innocence of a bedtime tale it might discern the truth of the placating purpose of story, or the tyranny of naïve narrative closure, the fantasies of teleology and final consonance. And behind Pascal’s wager it might find a weak submission to ideological fictions, a confirmation of the processes of social conditioning.Over the years suspicion has doubtless proved itself a crucial resource for various politics of resistance, for challenging ossified structures of knowledge, and for exposing heinous fictions that definitely needed exposing. But some contend that these once fruitful intellectual practices have become so deeply entrenched that they are now the things to be suspiciously overcome. Rather than being a subversive tactic of liberation, the “routinisation” of suspicion can stand to mark a hermeneutic stasis. It can even, as Bruno Latour argues, mire important social and ecological issues in counterproductive doubt, the most obvious example being the tiresome “debates” about global warming:the danger would no longer be coming from an excessive confidence in ideological arguments posturing as matters of fact—as we have learned to combat so efficiently in the past—but from an excessive distrust of good matters of fact disguised as bad ideological biases! (Latour 227) The work of David Foster Wallace can be considered another example of such a discourse, one that definitely admits suspicion’s hermeneutic force, but is a little uneasy with its predominance. While Wallace’s work is most commonly understood in relation to irony, irony itself, as I have suggested, can in turn be understood as related to a subtending culture of suspicion and cynicism. In his 1993 essay “E Unibus Pluram: Television and U.S. Fiction,” Wallace notes a complex interaction between knowledge, suspicion, art, and televisual culture, in which a particular rendering of irony—a mistrust in clichéd sentiment and all those words we now so confidently put between “shudder” quotes—is commoditised and exploited in order to constantly provide the psychological payoffs of knowingness, those feelings of superiority, safety, and power that come from suspiciously seeing through to the “truth” of things. In Wallace’s reading, ostensibly postmodern advertisements draw attention to their fictive layers to make viewers feel attuned to the supposed truth of their intent. But this access to the “truth” is itself just another fiction aimed to mislead them into commercial pliancy:[TV can] ease that painful tension between Joe’s need to transcend the crowd and his status as Audience member. For to the extent that TV can flatter Joe about “seeing through” the pretentiousness and hypocrisy of outdated values, it can induce in him precisely the feeling of canny superiority it’s taught him to crave, and can keep him dependent on the cynical TV-watching that alone affords this feeling. (Wallace 180) The ironic viewer who would stand above these deliberately naive appeals would then also, and perhaps before anything else, be a suspicious reader, someone predisposed to seeing through the “surface” of a text. Irony, in these examples, would even be alike to the effect gained from “successful” suspicion, something like its reward, rather than an epistemological mode in itself. While in his essay Wallace ultimately intends that his critique of such tendencies will highlight the way much contemporary fiction struggles to subvert this culture, and thus we cannot help but look to his own work to see how it supposedly “attacks” irony, it is also just as crucial to consider its embedded critique of suspicious hermeneutics.II Trust In Infinite Jest’s portrayal of Boston’s Alcoholics and Narcotics Anonymous programs, Wallace attempts to propose a kind of neo-Pascalian “wager.” And like Pascal’s, Wallace’s is based on the willed performance of that most critically maligned of concepts, trust: that is, a willingness to become, like Pascal, blasé with truth as long as it stands to be beneficial. Within the novel the fictitious Ennet Drug and Alcohol House, along with the adjacent Enfield Tennis Academy, is staged as a school of personal (re)development, dramatising approaches to self-help in the damaged landscape of the Year of the Depend Adult Undergarment’s Boston. And it is here where Don Gately, the novel’s unlikely hero, has ended up on his quest to escape the “spider” of addiction. As it openly admits, Alcoholics Anonymous is an easy target for a suspicious mode of thought bent on locating fictions because it “literally makes no sense” (368). But like Pascal, Wallace’s AA submits the problem of truth and error to a more primary consideration of benefit, and celebrates the power of language and custom to create realities, rather than being suspicious of this process of linguistic mediation. So it is a system, like signification itself, that functions on “the carrot-and-donkey aspect of trudging to Meetings only to be told to trudge to still more Meetings” (1001); like any transcendental signifier, the revelations it hints at can never truly arrive. It is also based on assertions that “do not make anything resembling rational sense” (1002). For example, Joelle van Dyne battles with the AA precept “I’m Here But For the Grace of God.” She finds the phrase is literally senseless, and regardless of whether she hears it or not it’s meaningless, and that the foamy enthusiasm with which these folks can say what in fact means nothing at all makes her want to put her head in a Radarange. (366) But perhaps the strongest reason Joelle feels uncomfortable with the present example is that she senses in its obvious untruth the potential truth of all meaning’s fictitiousness, how all sense might just be made up of nonsense of one form or another. Within the AA program these words are a means to an end, rather than something to be resisted or deconstructed.To exist within Infinite Jest’s AA program is thus to be uncomfortably close to the linguistic production of reality, to work at meaning’s coalface, exposed to the flames of its fictitiousness, but all the while being forced to deny this very vista. So while AA is a process firmly against the mechanisms of denial (one of its favourite slogans is “Denial is not a river in Egypt” [272]), it is also based on a paradoxical imperative to deny the status of meaning as a production, as well as the denial of the significance of this paradox: For me, the slogan [Analysis-Paralysis] means there’s no set way to argue intellectual-type stuff about the Program [...] You can’t think about it like an intellectual thing [...] You can analyse it til you’re breaking tables with your forehead and find a cause to walk away, back Out There, where the Disease is. Or you can stay and hang in and do the best you can. (1002) Although it is common knowledge that its precepts are full of logical contradiction and impasse, that it is a blatantly fictitious enterprise, the difficulty which Wallace’s portrayal poses, both for his characters and for his readers schooled in suspicious hermeneutics, is that as a process of healing the AA program somehow seems to work with great efficacy. Enter the redemption of Don Gately.Despite his initial reluctance to embrace the program’s undertakings, much to his surprise Gately finds it having a definite effect: he “all of a sudden realised that quite a few days had gone by since he’d even thought about Demerol or Talwin or even weed” (467). The bracketing of the desire to know and interpret, and the willed trust in the efficacy of a process that one cannot know by necessity, initially frustrates him, and even makes him suspicious: “He couldn’t believe it. He wasn’t Grateful so much as kind of suspicious about it, the Removal [of his addiction]” (468). And all this can definitely be intellectually uncomfortable for a reader well-versed in suspicious hermeneutics, let alone the somewhat unintellectual Gately:It did, yes, tentatively seem maybe actually to be working, but Gately couldn’t for the life of him figure out how just sitting on haemorrhoid-hostile folding chairs every night looking at nose-pores and listening to clichés could work. Nobody’s ever been able to figure AA out, is another binding commonality. (349)Ultimately the AA program presents the novel’s hero and its readers with an impasse, a block to what one knows and can critique, refuting the basic assumption that links narrative progression and change with the acquisition of knowledge. While others in AA seek to understand and debunk it, they also significantly fail to achieve the kind of recovery experienced by Gately. As Elizabeth Freudenthal suggests, “despite the problems one may have with AA as a vehicle for healthy living, Gately’s mode of fighting addiction is the only one in the novel that actually works” (191). And while Freudenthal suggests that Gately’s success comes through a ritual “anti-interiority,” a “mode of identity founded in the material world of both objects and biological bodies and divested from an essentialist notion of inner emotional, psychological, and spiritual life” (192), to me it seems that were Gately unable to resist the pleasures of the suspicious mind then little of his “abiding” in the exterior world would be possible. Ultimately, what Gately achieves comes through a kind of epistemological “trust.”III Reading TrustfullyBy occupying such a central place in the narrative, this neo-Pascalian wager around which the novel’s AA program is built is obviously intended to bear not only on its characters, but on how the novel is read. So how might we also “learn” from such Pascalian gambits? How might we read the novel without suspicion? What might we gain by becoming Don Gately? What, on the other hand, might we lose? While this essay is far too short to conduct this kind of investigation in full, a few points might still be raised in lieu of a proper conclusion.By openly submitting to his ignorance of what his actions mean, Gately is able to approach success, conclusion, and fulfillment. What the novel’s ending has in store for him is another question altogether, but Freudenthal views Gately’s closing scenes as the apotheosis of his “anti-intellectual endeavor” (206). Gately’s narrative thus also presents a challenge to readers thoroughly led by suspicious hermeneutics, and encourages us, if we are to accept this notion that is key to Infinite Jest (but we can, of course, refuse not to), to place ourselves in the position of the AA attendee, as a subject of the text’s discourse, not in possession of knowledge through which to critique it and scale that “architecture of meaning.” Many aspects of the novel of course impel us to read suspiciously, to gather clues like detectives, to interrogate the veracity of claims. Consider, for example, the compounded conflicting accounts of whether Joelle van Dyne has been horribly disfigured by acid, or is sublimely beautiful (compare, for instance, the explanation given on 538 with that on 795). Yet ultimately, recalling the AA ethos, the narrative makes it difficult for us to successfully execute these suspicious reading practices. Similar to a text like Thomas Pynchon’s Gravity’s Rainbow, that for Brian McHale ultimately resists any attempt to answer the many questions it poses (90-91), Infinite Jest frequently invokes a logic of what we might call epistemological equivocation. Either the veil-wearing Joelle van Dyne is hideously and improbably deformed or is superlatively beautiful; either AA is a vapid institution of brainwashing or is the key to recovery from substance abuse; either the novel’s matriarch, Avril Incandenza, is a sinister “black widow” or a superlatively caring mother. The list goes on.To some extent, the plethora of conflicting accounts simply engages an “innocent” readerly curiosity. But regardless of the precise nature of this hermeneutic desire stimulated by the text, one cannot help but feel, as Marshall Boswell suggests, that “Wallace’s point seems to be that these issues are not the issue” (175). If we read the novel attempting to harmonise these elements, interrogating the reliability of the given textual evidence, we will be sorely disappointed, if not doomed to the “analysis paralysis” that is much feared in the novel’s AA program. While one of the pleasures Wallace’s novel offers readers is the encouragement to participate actively in the text, it is also something it is wary of. And this is where the rub of the book lies. Just like in AA, we can potentially keep analysing its ambiguities forever; it is indeed designed to be pleasurable in just this way. But it is also intended, at least so Wallace tells us, to resist the addictive nature of pure entertainment:The original title was A Failed Entertainment. The idea is that the book is structured as an entertainment that doesn’t work [...]. And the tension of the book is to try to make it at once extremely entertaining—and also sort of warped, and to sort of shake the reader awake about some of the things that are sinister in entertainment. (Wallace in Lipsky 79)If we consider what it might mean to view the book as a “Failed Entertainment,” and consider what it is we love to do when reading suspiciously, we can then see that it is perhaps intended to steer us away from trying to decode it, especially when it is constantly suggested to us that it is this effort of analysis that tends to move one out of the immediacy of a given moment. The fact that “nobody’s ever been able to figure AA out” (349), yet it still indubitably works, seems to suggests how we are to approach the novel.But what are we offered instead of these pleasures of suspicious reading? Perhaps, like the AA attendee, the novel wants us to learn to listen to what is already in front of us: for the AA member it is all those stories offered up at the “podium”; for us it is all the pain and joy written in the text. In place of a conclusive ending that gives us all that we want to know, that shows us everything that “happens,” in its final scene the novel instead tells the story of a man finding his “bottom,” his lowest ebb, waking up “flat on his back on the beach in the freezing sand” (981). This man, of course, is Don Gately. If we see this final moment only as a frustration of narrative desire, as a turning away from full understanding, from a revelation of the “truth” the narrative has been withholding, then we perhaps fail the task Wallace’s text, like AA, constantly asks of us: to listen, to accept, to trust.ReferencesBoswell, Marshall. Understanding David Foster Wallace. Columbia, SC: U of South Carolina P, 2003.Bywater, William. “The Paranoia of Postmodernism.” Philosophy and Literature 14.1 (1990): 79–84. Foucault, Michel. “Nietzsche, Freud, Marx.” Aesthetics, Method, and Epistemology: Essential Works of Foucault 1954–84, Volume 2. Ed. James Faubion. Trans. Robert Hurley et al. London: Penguin, 2000. 269–78. Freudenthal, Elizabeth. “Anti-Interiority: Compulsiveness, Objectification, and Identity in Infinite Jest.” New Literary History 41.1 (2010): 191–211. Kelly, Adam. “David Foster Wallace and the New Sincerity in American Fiction.” Consider David Foster Wallace: Critical Essays. Los Angeles: Sideshow Media Group Press, 2010. 131–46.Latour, Bruno. “Why Has Critique Run Out of Steam? From Matters of Fact to Matters of Concern.” Critical Inquiry 30.2 (2004): 225–48.Lipsky, David. Although of Course You End Up Becoming Yourself: A Road Trip With David Foster Wallace. New York: Broadway Books, 2010.McHale, Brian. “Modernist Reading, Post-Modern Text: The Case of Gravity's Rainbow.” Poetics Today 1.1 (1979): 85–110.Pascal, Blaise. Pensées and Other Writings. Trans. Honor Levi. Ed.Anthony Levi. New York: Oxford UP, 1995.Ricœur, Paul. Freud and Philosophy: An Essay on Interpretation. Trans. Denis Savage. New Haven: Yale UP, 1970.Wallace, David Foster. “E Unibus Pluram: Television and U.S. Fiction.” Review of Contemporary Fiction 13.2 (1993): 151–94. ---. Infinite Jest. New York: Back Bay Books, 1996.

Background. The COVID-19 pandemic affected all medical education because of the suspension of face-to-face learning and stringent protocols. Various methods of teaching were introduced to augment anatomical learning.Objective. As we enter the transition period and loosening of protocols for face-to-face learning, we want to know if these modes of teaching are still preferred and suitable or the traditional proctor-assisted dissection is preferable among first year medical students.Methods. This descriptive cross-sectional study recruited first-year medical students currently enrolled at the University of the Philippines College of Medicine during the Department of Anatomy Learning Enhancement Program (LEAP) from June 13-17, 2022. One station caters to musculoskeletal anatomy. The musculoskeletal station is further divided into four mini stations: a prosected lower extremity cadaver with labels of must know anatomic structures for the proctor-assisted cadaver dissection; a prosected lower extremity with a self-directed manual for the students to follow; a large screen television for the dissection educational videos focusing on the shoulder girdle; and lastly, skeletons for osteology. Thirty minutes were allotted per sub-station in the musculoskeletal station of LEAP. After completing the station, the students were provided with evaluation forms and a 30-item survey to determine the preferred teaching modality in musculoskeletal anatomy.Results. A total of 145 students out of the 178 students participated and answered the survey and evaluation form. Ninety-nine percent of the students rated the proctor-assisted dissection station great and excellent (13% and 86% respectively) and that 86% of the students preferred proctor-assisted dissection among the teaching modalities. Additionally, 89% (46% strongly disagreed and 43% disagreed) and 83% (55% strongly disagreed and 28% disagreed) of the students disagreed that they prefer self-directed module or dissection educational videos over traditional dissection, respectively. Mostof the students also agreed that the inability of face-toface dissection will affect their medical education (35% agreed and 64% strongly agreed) and majority of them thinks that cadaver dissection is vital in their medical education and towards becoming a doctor (14% agreed, 86% strongly agreed). Conclusion. With the plethora of teaching modalities introduced during the pandemic, medical students still preferred the traditional proctor-assisted dissection. However, they see the value of the other teachingmodalities as an added armamentarium in enhancing anatomical knowledge.

Showtime’s reality TV series Family Business opens with a black screen and audio: the whirring of a 16mm projector, the home movies of a generation ago. The sound connotes nostalgia, memory, family, and film. In my childhood, the sound of the projector meant family time, a glance back at our toddler years, the years of Sunday dinners in the suburbs, when my mother and all my aunts still smoked. Later, as my sister and cousins whose childhoods are fixed in that celluloid began to date and marry, family movies were a means of introducing the soon-to-be-married other into the family; this was how we told our history. This kind of telling is one side of Family Business. The other, as Adam Glasser reports in his voiceover in the opening credits is “just one more thing. My business is entertaining adults.” Glasser, producer, director and occasional actor, is known in the adult entertainment industry as Seymore Butts, alluding to his particular personal and professional interest in anal sex. He self-describes, in the opening credits of Family Business, as “a pretty average guy,” a single father who runs his business with help from his mother and cousin. Viewers glance over Glasser’s shoulder into his everyday life as he cooks breakfast for his son, dates women in his ongoing search for a lasting relationship, and goes about the business of producing pornography. Family Business uniquely combines two genres that trouble perceptions of reality mediated through television, pornography and reality TV. Reality television troubles the real by effectively blurring the lines between the actual and the contrived. With the genre of reality TV now firmly in place, viewers take pleasure in reading between those lines, trying to determine what aspects of the characters, contexts and events of a television program are “authentic”. Searching for the real demands the viewer suspend disbelief, conveniently forgetting the power of the camera’s presence. Scripted or not, the camera is always played to, suppressing the “real” in favor of performance. Like reality TV, pornography blurs the line between reality and fantasy. As Elizabeth Bell points out, the difference between soft-core pornography and hard-core pornography is the difference between simulated and real sex. Hard-core porn depends on “an ironic tension between ‘real’ sexual acts within ‘faked’ sexual contexts” (181), troubling the viewer’s sense of whether such performances could “really” take place. The lingering disbelief sets porn apart from one’s personal sex life, just as questioning the authentic in reality TV keeps it from being “real.” Reality TV plays on a tension similar to Bell’s description of hard-core pornography. Manufactured contexts succinctly expose the personalities of the actors/ordinary people who are featured on reality TV programs. As a result, the audience can gain familiarity with these individuals in a neat thirty or sixty minute time slot. Inherent in any TV series is the notion that the audience forms opinions about and alliances for or against certain characters, stepping into their lives, mediated as they are, each week. Kenneth Gergen notes that “so powerful are the media in their well-wrought portrayals that their realities become more compelling than those furnished by common experience” (57). By conflating pornography with the everyday lives of its actors and directors, Family Business works to naturalize pornography by displaying it as real. When viewers are constantly sorting between the scripted and the spontaneous, where do they locate the real on Family Business? In a mediated world, the search for the real is always already fruitless: viewers and producers of reality TV recognize that the chasm between lived experience and the depiction of lived experience on television and film can’t be crossed. Reality TV and pornography both work to bring the mediated image closer to the experience of the viewer, placing “people just like you” in everyday situations that brush up against the outrageous. Laura Kipnis argues that pornography does not reflect reality but is “mythological and hyperbolic, peopled by fictional characters. It doesn’t and never will exist.” While pornography does not try to claim itself as real, Kipnis says, it does “insist on a sanctioned space for fantasy.” Acknowledging that space, and declaring that “normal” people engage the fantasy of porn, is important cultural work for Glasser. An episode of Family Business features Glasser giving a class on ways to please your partner using methods he learned in the industry. He speaks in interviews about letters he has received, proclaiming that the Seymore Butts films have enhanced couples’ sex lives. Family Business is not only important cultural work for Glasser; it is also important professional work. Naturalizing pornography, and giving viewers a glimpse of Seymore Butts films, certainly helps his product sales. Seeing Family Business as part of the mainstreaming of pornography, Glasser says “it’s the natural course of things” for pornography to be increasingly accepted. “Sex is just so much a part of mainstream people’s lives. So it’s natural that they would be curious about sex and people who have sex for a living” (Brioux). Adam Glasser “is” Seymore Butts, or is he? Viewers are exposed to a character-within-a-character: Glasser as father, son, and entrepreneur is difficult to separate from Glasser as Butts—adult entertainment producer and actor, porn celebrity. Glasser does not appear to distinguish between these identities, but is presented as one person seamlessly performing the everyday roles of his chosen life. He is a role model for the normalizing and mainstreaming of pornography. Family Business aspires to naturalize the integration of pornography into everyday life, naturalizing the adult entertainment industry, its producers and ultimately, its consumers. Viewers see Glasser as a fun-loving, single dad who plays baseball with his son. We look on as his Cousin Stevie, nearing 60 years old, goes to the doctor for a prostate exam (which the audience voyeuristically enjoys, is repelled by, and is compelled by to tend to health concerns). That Glasser and Cousin Stevie are also producers and distributors of adult entertainment enables the viewer to naturalize her/his own consumption of pornography. Fans posting on Showtime’s Family Business message board question whether the show authentically depicts the “real” lives of its characters, with discussions about what scenes are staged and scripted. Media consumption is seldom a passive practice, and one of the pleasures of reality TV is the audience’s resistance to what is presented as “real.” While the everyday lives of the characters are hotly debated on the message board, there is little discussion of pornography, beyond assertions of support for and the rare protest against adult entertainment on cable television. The Seymore Butts movies are rarely mentioned. What Family Business gives viewers access to is a soft-porn version of the staging of Seymore Butts films, as much as censors allow for MA cable programming. According to Bell, “all theoretical treatments of hard-core pornography…begin with the declaration that the performers are engaged in real sexual activity” (183). Glasser categorizes his porn as hard-core, but should fans believe it is authentically real, not just real sex acts but also a reflection of real life? He claims that it is: “My adult movies that I’ve made for the last 12 years have been what you would call reality based,” Glasser says. “They’re basically a documentation of my life, my relationships, good and bad.” (Haffenreffer). Glasser’s documentary of his life and relationships, however, is mediated through the lens of his camera and work in the editing room, presented in such a way to be compelling to its audience. Whether there is something intrinsically real in the Seymore Butts films, the contexts of the films are certainly contrived. Viewers of Family Business see Glasser describe fantasy scenarios to the actors preparing for a scene. While the situations are more mundane than fantastic, the implausibility of a group of people spontaneously having sex while waiting for friends to come back from lunch, for example, places Glasser’s pornography in a liminal space between fantasy and the real. What renders these films different from other pornography and makes them somewhat more believable is precisely the mundane scenarios in which they occur. The conflation of pornography and the everyday is reinforced spatially on Family Business: viewers see Glasser shoot a porn film in his living room, where sexual acts are performed on the same sofa where, in another scene, Glasser’s mother Lila plays with his son, Brady. After a comment about this was posted on the show’s message board, Flower, one of Glasser’s “Tushy Girls” posted a response: “But in defence [sic] of Semyore, He has his furniture steam cleaned after every shoot. Have you ever heard of kids laying or sitting on their parents [sic] bed? Don’t parents have sex too? I’m sure plenty of kids have sat where people have had sex before. So I don’t find it strange.” What Flower asks of message board readers is the normalization of pornography, a blending of porn and private sex acts into the same category. Family Business works to eradicate the perceptions of pornography that Kipnis describes as “all the nervous stereotypes of pimply teenagers, furtive perverts in raincoats, and anti-social compulsively masturbating misfits.” Pornography is not situated in the world of the outcast, Kipnis argues. Rather, it is “central to our culture,” simultaneously revealing our mostly deeply felt desires and fears. The series functions to relieve its viewers of the sense of guilty indiscretion. It typically airs on Friday nights at 11:00 p.m., the opening of Mature Adult-rated programming on cable television. Family Business is not only pornography, it also presents itself as a family sitcom. The show provides a neat segue from prime-time programming to after-hours, commingling the two genres for viewers to seamlessly make that shift themselves. Week after week, viewers of Family Business find the conflation of pornography and everyday life more acceptable. In sharp contrast to the sordid, sad life stories of Linda Lovelace, the Mitchell brothers and organized crime that are stitched into the history of pornography, Adam Glasser is presented as a respectable public figure, a free speech activist with a solid moral foundation. The morality or immorality of adult entertainment is not questioned here: inherent in Family Business is the idea that “they” have rendered sexual expression immoral where “we” (the characters in the series and the viewers at home) are accepting of, and even committed to, the pleasures of sex. As presented on Family Business, Glasser’s lifestyle is rather morally sound. There is no drug use, not even cigarette smoking, and although a pack of Merits appears occasionally in the pocket of Cousin Stevie’s stylish shirt, he does not smoke on camera. Safe sex is a priority, and the actors are presented as celebrating and enjoying their sexuality. The viewer is encouraged to do the same. The everyday behavior of the cast of Family Business is far from extraordinary, as Glasser takes pains to point out. Comparing Family Business to The Osbournes, he says “they are outrageous people in a normal world, and we’re normal people in an outrageous world” (Hooper). We’ve come to tolerate the Osbournes, perhaps even pitying them at times as if they have no control over their own outrageousness. Can viewers accept the outrageous in Family Business? Certainly the mundane lives of Adam and Lila—a nice Jewish boy from Brooklyn and his dear, doting mom—indicate that normal people can accept the outrageous world of pornography, so why should we not accept it as well? Tolerating Family Business is, essentially, tolerating pornography. Bringing the backstage of the adult entertainment industry into the frontstage of cable television programming marks a desire to shift the uses of pornography. Rather than being an underground outlet for sexual deviance, Family Business works to make porn a reflection of our everyday personal and sexual lives. Kipnis notes there is “virtually no discussion of pornography as an expressive medium in the positive sense—the only expressing it’s presumed to do is of misogyny or social decay.” Viewers can openly chat about Family Business and the glimpse it offers into the world of pornography, without the shame or embarrassment that would run alongside a discussion of porn itself. When sexual pleasure enters the public discourse through mainstream entertainment, there is power for those who fight against conservative voices wishing to suppress not just pornography but also sexual pleasure. References Bell, Elizabeth. “Weddings and Pornography: The Cultural Performance of Sex.” Text and Performance Quarterly 19 (1999): 173-195. Brioux, Bill. “A Family Affair: New Show Takes a Peek Behind Adam Glasser’s Porn Business.” The Toronto Sun. 3 October 2003, final ed.: E11. Gergen, Kenneth J. The Saturated Self: Dilemmas of Identity in Contemporary Life. New York: Basic Books, 2000. Haffenreffer, David. “Reality Imitates Art: When the ‘Family Business’ is in the Sex Industry.” CNN.com. 13 January 2004. Hooper, Barrett. “‘Normal people in an outrageous world’: Adam Glasser, star of the reality TV show Family Business, is just a regular guy who also happens to be a porn producer.” National Post. 5 December 2003: B4. http://www.pbs.org/wgbh/pages/frontline/shows/porn/special/eloquence.html MLA Style Levitt, Linda. "Searching for the Real: “Family Business,” Pornography, and Reality Television." M/C Journal 7.4 (2004). 10 October 2004 <http://www.media-culture.org.au/0410/04_searching.php> APA Style Levitt, L. (2004 Oct 11). Searching for the Real: “Family Business,” Pornography, and Reality Television, M/C Journal 7(4). Retrieved Oct 10 2004 from <http://www.media-culture.org.au/0410/04_searching.php>

The pop cultural moment that most typifies the social psychology of invasion for many of us is Orson Welles's 1938 coast to coast CBS radio broadcast of Invaders from Mars, a narration based on H.G. Wells's The War of the Worlds. News bulletins and scene broadcasts followed Welles's introduction, featuring, in contemporary journalistic style, reports of a "meteor" landing near Princeton, N.J., which "killed" 1500 people, and the discovery that it was in fact a "metal cylinder" containing strange creatures from Mars armed with "death rays" which would reduce all the inhabitants of the earth to space dust. Welles's broadcast caused thousands to believe that Martians were wreaking widespread havoc in New York and Jersey. New York streets were filled with families rushing to open spaces protecting their faces from the "gas raids", clutching sacred possessions and each other. Lines of communication were clogged, massive traffic jams ensued, and people evacuated their homes in a state of abject terror while armouries in neighbouring districts prepared to join in the "battle". Some felt it was a very cruel prank, especially after the recent war scare in Europe that featured constant interruption of regular radio programming. Many of the thousands of questions directed at police in the hours following the broadcast reflected the concerns of the residents of London and Paris during the tense days before the Munich agreement. The media had undergone that strange metamorphosis that occurs when people depend on it for information that affects themselves directly. But it was not a prank. Three separate announcements made during the broadcast stressed its fictional nature. The introduction to the program stated "the Columbia Broadcasting System and its affiliated stations present Orson Welles and the Mercury Theatre on the Air in The War of the Worlds by H.G. Wells", as did the newspaper listing of the program "Today: 8:00-9:00 -- Play: H.G. Wells's 'War of the Worlds' -- WABC". Welles, rather innocently, wanted to play with the conventions of broadcasting and grant his audience a bit of legitimately unsettling, though obviously fictitious, verisimilitude. There are not too many instances in modern history where we can look objectively at such incredible reactions to media soundbytes. That evening is a prototype for the impact media culture can have on an audience whose minds are prepped for impending disaster. The interruption of scheduled radio invoked in the audience a knee-jerk response that dramatically illustrated the susceptibility of people to the discourse of invasion, as well as the depth of the relationship between the audience and media during tense times. These days, the media itself are often regarded as the invaders. The endless procession of information that grows alongside technology's ability to present it is feared as much as it is loved. In the current climate of information and technological overload, invasion has swum from the depths of our unconscious paranoia and lurks impatiently in the shallows. There is so much invasion and so much to feel invaded about: the war in Kosovo (one of over sixty being fought today) is getting worse with the benevolence and force of the UN dwindling in a cloud of bureaucracy and failed talks, Ethiopia and Eritrea are going at it again, the ideology of the Olympic Games in Sydney has gone from a positive celebration of the millennium to a revenue-generating boys club of back scratchers, Internet smut is still everywhere, and most horrifically, Baywatch came dangerously close to being shot on location on the East Coast of Australia. In this issue of M/C we take a look at literal and allegorical invasions from a variety of cleverly examined aspects of our culture. Firstly, Axel Bruns takes a look a subtle invasion that is occurring on the Web in "Invading the Ivory Tower: Hypertext and the New Dilettante Scholars". He points to the way the Internet's function as a research tool is changing the nature of academic writing due to its interactivity and potential to be manipulated in a way that conventional written material cannot. Axel investigates the web browser's ability to invade the text and the elite world of academic publishing via the format of hypertext itself rather than merely through ideas. Felicity Meakins's article Shooting Baywatch: Resisting Cultural Invasion examines media and community reactions to the threat of having the television series Baywatch shot on Australian beaches. Felicity looks at the cultural cringe that has surrounded the relationship between Australia and America over the years and is manifested by our response to American accents in the media. American cultural imperialism has come to signify a great deal in the dwindling face of Aussie institutions like mateship and egalitarianism. In a similarly driven piece called "A Decolonising Doctor? British SF Invasion Narratives", Nick Caldwell investigates some of the implications of the "Britishness" of the cult television series Doctor Who, where insularity and cultural authority are taken to extremes during the ubiquitous intergalactic invasions. Paul Mc Cormack's article "Screen II: The Invasion of the Attention Snatchers" turns from technologically superior invaders to an invasion by technology itself -- he considers how the television has irreversibly invaded our lives and claimed a dominant place in the domestic sphere. Recently, the (Internet-connected) personal computer has begun a similar invasion: what space will it eventually claim? Sandra Brunet's "Is Sustainable Tourism Really Sustainable? Protecting the Icon in the Commodity at Sites of Invasion" explores the often forgotten Kangaroo Island off the coast of South Australia. She looks at ways in which the image of the island is constructed by the government and media for eco-tourism and how faithful this representation is to the farmers, fishermen and other inhabitants of the island. Paul Starr's article "Special Effects and the Invasive Camera: Enemy of the State and The Conversation" rounds off the issue with a look at the troubled relationship between cutting-edge special effects in Hollywood action movies and the surveillance technologies that recent movies such as Enemy of the State show as tools in government conspiracies. The depiction of high-tech gadgetry as 'cool' and 'evil' at the same time, he writes, leads to a collapse of meaning. This issue of M/C succeeds in pointing out sites of invasion in unusual places, continuing the journal's tradition of perception in the face of new media culture. I hope you enjoy this second issue of the second volume: 'invasion'. Ben King 'Invasion' Issue Editor Citation reference for this article MLA style: Ben King. "Editorial: 'Invasion'." M/C: A Journal of Media and Culture 2.2 (1999). [your date of access] <http://www.uq.edu.au/mc/9903/edit.php>. Chicago style: Ben King, "Editorial: 'Invasion'," M/C: A Journal of Media and Culture 2, no. 2 (1999), <http://www.uq.edu.au/mc/9903/edit.php> ([your date of access]). APA style: Ben King. (1999) Editorial: 'invasion'. M/C: A Journal of Media and Culture 2(2). <http://www.uq.edu.au/mc/9903/edit.php> ([your date of access]).

This keynote lecture is a product of many years of hard work but today this is delivered in honor of Professor and Founding President of ORLIAC, Professor Emeritus Jan Veldman. Thank you for the opportunity to host ORLIAC in Manila way back in March 2018. For those who attended this, I gave a special lecture during the celebration of World Hearing Day on March 3, 2018, when ORLIAC was held in Manila and this gives an update on how we managed in the past four and a half years, with a COVID-19 pandemic in the past two and half years. The Philippines is an archipelago of more than 7,100 islands during high tide and up to 7,600 when it is low tide. It is situated in the Southeast Asian region. It is one of the countries with the highest population density, with a total population of 110 million spread over 300,000 square kilometers. The crude birthrate is at 19.9 per 1000 – in stark contrast with surrounding Southeast Asian nations now with a decreasing population such as Thailand, Vietnam, and Malaysia among others There have been three World Health Assembly (WHA) resolutions that emphasized the prevention of deafness and hearing loss. WHA 38.19 in 1985 then ten years later WHA 48.9 in 1995 and the last WHA 70.13 in 2017. These resolutions from the World Health Assembly emphasized that prevention of deafness and hearing loss should be incorporated in primary health care. As a result of the 2017 WHA 70.13 resolution, a World Hearing Report1was formulated and released last year in 2021 (Figure 1). The WHO Call to Action in 2000 recommended that Universal Newborn Hearing Screening (NHS) be implemented in all countries where rehabilitation services are established.2 In 1998, we did the first cochlear implantation in my country3 and established as well the graduate program of Masters in Clinical Audiology at the UP College of Medicine where I now work as Dean. This graduate program is one of only two in the country and is government-subsidized such that slots are limited and entry is quite competitive. It is jointly offered with the College of Allied Medical Professions.4 We consider this program to be a key element in producing the necessary healthcare workforce needed for the implementation of programs to defeat deafness in my country. The world hearing report published last year by the World Health Organization (WHO) highlighted the increasing number of people living with hearing loss and in need of services. There is of course the disproportionate burden of hearing loss in low-to middle-income countries like the Philippines.6Our publications from 2003, from a study looking at results of newborn hearing screening in the neonatal intensive unit in the hospital7,8 then to the community, thus providing the evidence for the eventual policy on UNHS that we proposed to the Department of Health (DOH) and to congress for legislation.We initially embarked on basic epidemiological studies using otoacoustic emissions testing in the hospital then in the community. We noted the age of referral at our hospital for children with hearing impairment to be at around 34 months.9 Our focus then was just providing otological clinical services so we decided to work for the establishment of the Philippine National Ear Institute (PNEI) – a research institute formed by Republic Act 9245 and part of the National Institutes of Health of the University of the Philippines – Manila.10 The PNEI laid down the researches needed for the stable foundation of a national health program focused on newborn hearing. From 2003 to 2008, we conducted several studies to establish the prevalence of bilateral permanent hearing loss in newborns both in the hospital and community settings as a prelude to the enactment of the law, and in order to defend having a program on newborn hearing, we conducted a cost-analysis of hospital-based universal newborn hearing screening.11 Notably in 2007, a population-based study showed the prevalence of bilateral profound Congenital Hearing Loss at 1.4 per 1000 births.12 This translates to more than 3,000 babies annually or 8 babies per day who may be profoundly deaf in my country.13 If there were proper intervention for a child with hearing impairment, the cost of treating hearing translates to a lifetime savings of about 80,000 dollars or about PhP 4.3M for the patient’s family. The government and the family would have spent about PhP 4.3 M to raise, educate, and support a deaf-mute child to adulthood. This was presented to the Senate of the Philippines and highlighted during the Inaugural Congress of the ASEAN Academy of Neuro-Oto-Audiology (AANOA). This was supported by Senator Loren Legarda, PNEI Director Dr. Generoso Abes, AANOA founding member Dr. Helmi Balfas, IFOS Regional Secretary Chong Sun Kim, PSOHNS President Gil Vicente, AANOA President Dato Lokman Saim, and Hearing International Secretary Dr. Norberto Martinez (Figure 2). Mandating NHS in the country also entailed involving stakeholders, including otolaryngologists from the different regions who committed to convince their local officials and local hospital administrators the need for instituting these newborn hearing screening programs. After we had the local data at hand, the PSOHNS created a task force on NHS and crafted a position statement on the need for UNHS. As then Vice President, we drafted the position paper that will be presented to Congress while at the same time seeking support from the Department of Health under DOH Secretary Francisco Duque who agreed that Philhealth should be able to support this program when enacted into law. A Technical Working Group was formed, gathering all stakeholders and service providers. Multiple meetings were held, groundwork for launch, and implementation of newborn hearing screening program were instituted with ten Collaboration for Newborn Hearing Screening Advocacy (CONHScA) annual symposia with otolaryngology, audiology, and other hearing screening advocates all over the country.14 (Figure 3). On August 12, 2009, President Gloria Macapagal-Arroyo signed RA 9709, an act that established universalnewborn hearing screening program for the prevention, early diagnosis, and intervention of hearing loss.15 On the modality to be used, reporting, accreditation and training, monitoring and evaluation, and most especially costing of the services and financing for sustainability were also done. We advocated for legislation on UNHS, and once ratified, developed a national program with the Department of Health as lead agency and continued with policy implementation as part of a national technical working group under the DOH. This led to the creation of national Newborn Hearing Screening Reference Center (NHSRC) that was inaugurated in 2013 at the National Institutes of Health with Professor Cor Cremers of Radboud University Nijmegen as special guest. We also started to increase the awareness on the importance of NHS even on national television (Figure 4). Aside from the cost-effectiveness study of hospital-based newborn hearing screening program, we also looked at the budget impact of a community-based UNHSP in the Philippines from both the public payer and the societal perspectives. This study of Rivera et al. published in 201716 showed that cost effectiveness is sensitive to treatment rate, prevalence, follow-up rate, number of rehabilitation sessions, and coverage of the program. It was not sensitive to cost per rehabilitation session, cost of diagnosis with OAE and ABR, education costs, refer rates, recurrent costs, cost of machines, and sensitivity rates. From the societal perspective, the UNHSP was found to be cost-saving for the full range of parameters tested for cost of screening, amplification, education, rehabilitation, and fixed program costs. Ensuring treatment of at least 31 percent and follow-up rate of 24% for a community-based newborn hearing would likely be important benchmarks. The technical arm of the lead agency for this program, the Department of Health, is the Newborn Hearing Screening Reference Center that gives assistance in defining and recommending NHS testing and follow-up protocols which include hearing screening methods, devices used, location, manner, and timing of newborn hearing screening testing. The current protocol uses the 2007 JCIH recommendation of 1-3-6 rule, with screening at 1 month, confirmation of hearing loss at 3 months, and appropriate intervention at 6 months of age.17 With respect to the preferred method of screening, the recent study by Neumann K et al. showed OAE as most prevalent in the country.18 Ten years ago in 2010, an initial web registry for reporting of the OAE results was formulated up to 2014 it was used in 9 centers which allowed gathering of preliminary data on the NHS program. From the data, there was a registry card that needed manual data encoding and in order to sustain operations, a 1 USD fee was levied per registration and was reimbursable thru Philhealth that paid around 4 USD per hearing screening test done. Personnel training, device, and facility certification standards were implemented for centers that chose to perform newborn hearing screening testing. Tiered categorization of centers was also done with screening centers as Category A, screening and diagnostic centers as category B, screening, diagnostic, and essential intervention with hearing aid amplification as category C, and the highest category D for centers with genetic testing and counselling, cochlear implantation surgery and speech rehabilitation services. Recent data showed there were 1072 category A, 18 category B and C, and 9 category D centers distributed all over the country (Figure 5). While some services were initially hampered by the COVID-19 pandemic, NHSRC defined safety protocols that needed to be followed. In an updated advisory, first released in April 2020, and is still in effect to date, NHSRC emphasizes that the centers should follow hospital/institution’s procedural protocol regarding disinfection and attire. Hearing tests in infants are non-invasive and non-aerosol producing procedures. The advisory also included recommendations in terms of timing, preparation, and testing procedures. One significant development that was accelerated during the pandemic was the online adaptation of the NHS personnel certifying course that was reported in recent publications by Rozul et al.19,20 To date, there have been about 3403 trained personnel in 1099 centers with significant increase noted in 2019 compared to previous years. This was not however reflected in the report of Neumann probably due to the time when data for this publication was collected prior to 2019. From the registry alone, the percent screened in the Philippines has been reported to be at least 7-13 percent of live births from the years 2019-2021. The report from Philhealth of 800 claims for NHS from 2018-2019 is still under verification. In 2020, based on manual submission, out of 1099 facilities, 26 percent submitted reports. In 2019, 95% already submitted reports so the pandemic impacted significantly on reporting of results by excel file and paper reports (Figures 6 and 7). The program is still beset with challenges like poor compliance with data submission, loss to follow-up, poor connectivity, sustainable funding of the program from both local and national government, lack of human resources, and a need of much awareness among stakeholders regarding the importance of newborn hearing screening. In a country where 60 percent die without seeing a doctor, there is much work to do. The cost of screening equipment is a major barrier so we conceptualized a biomedical device development project working with engineers in the university to create an AABR screening device which is now on phase two with a TLR 5 early phase rating scale and will now include recruitment of more subjects and refinements for improvements. Harnessing technology and making this more affordable remain as strategies for developing a sustainable hearing screening program and is the subject of HELE, which aims to increase the rates of newborn hearing screening with novel technologies and telehealth. “Hele” stands for lullaby a mother sings to a child. We thought this as very apt for emphasizing the importance of hearing from birth for optimal development. This received a substantial phase 1 grant in 2016 and a phase 2 was launched this year for the premarket development which now stand at technology readiness level 5. It has already spawned many products like the computer-based e-learning training modules, capacity building with provision of basic OAE equipment, and many research publications. It is hoped that a pre-production HELE device can already be produced soon with validated efficacy and reproducibility of all the AABR responses in a clinical setting. With the collaboration of University of California Berkeley and UC Davis, a formidable team has been created. The electronic national newborn hearing screening registry was launched during WORLD HEARING DAY in 2022 and the usability testing results have been published by Ricalde et al.21 In the recent manual of operations and procedures, success indicators were outlined. This is aligned with the WHO standards for monitoring and evaluation, and determining success of programs. Beyond NHS, what else have we learned? Our studies on the genetic causes of the more common causes of hearing impairment such as otitis media showed a unique mutation A2ML1 that affected protease inhibitors allowing better mucosal defense of the middle ear mucosa. Our findings showed microbiome shifts and when we looked at gingivitis, this was what we found. The genetic counseling we embarked on for this indigenous community taught us clinicians many lessons. Speaking to them in their native language was important and house to house invitations were more effective. What about genetic basis of congenital hearing loss? We have found that SLC26A4 mutations were more common than GJB2. There were novel mutations seen in our cohort suggesting the need for studies looking at genetic predisposition. We saw commonalities with Indonesia in terms of the prevalence of GJB2 mutations. From our studies on A2ML1 mutations predisposing to otitis media, we are monitoring this with ongoing study on Hispanic populations. Meanwhile, a seed fund for a national cochlear implant program was approved by Congress and 20 children underwent surgery (Figure 8), while two centers, one in Visayas (Corazon Locsin Montelibano Memorial Regional Hospital in Bacolod) and another in Mindanao (Southern Philippines Medical Center in Davao) were capacitated. Virtual multidisciplinary meetings to discuss the cases were held and provided a model for optimizing use of resources and outcomes. The initial data from the 20 implanted children are very encouraging. There are goals of expanding this program to more beneficiaries by having a Z package for Cochlear implantation, funding from DOH medical assistance fund for indigent patients, and development of services for other implantable hearing devices at the Philippine General Hospital. Moreover, research on hearing need more support given that our studies on genetics of hearing loss among Filipinos yielded very important data on novel genes, uniqueness of our genetic pool as well as mutations predisposing to increased prevalence of otitis media among our marginalized and indigenous population.22-26 As a low- to middle-income country, these researches will need to be continued and may provide valuable lessons for similarly challenged countries in the works as we highlighted in 2017 during the United Nations World Hearing Assembly Advocacy Event on hearing health (Figure 9). The recent National Academy of Science and Technology health policy forum where Professor Xing Kuan Bu was featured as keynote lecturer gave important data on experiences on hearing health program development in China and in the world (Figure 10). Clearly the sustainable development goals especially 3,4,8 and 10 covered by hearing health ensures equity and should be aspirational goals for national development. This is congruent with the vision of PNEI: “No Filipino shall be deprived of a functioning sense of hearing and balance.” Lastly, as the theme of this congress is East Meets West, the Philippines had a strong history of shipbuilding in an era when the galleon trade was very active and 148 of 200 ships that plied that route were ships built in the Philippines with our hardwood. Tracing therefore the history of the countries in ASEAN in particular with the Dutch, French, British, and Spanish influences, we need to dig deeper and look at genetic markers for both health and disease so that while we develop our friendship and scientific connections, history will prove that we have always been connected in so many ways and further exploration can be done in many dimensions. Charlotte M. Chiong, MD, PhDResearch Professor 12Project Leader of HeLeDean, UP College of Medicine (2018-present) _____________________________Paper presented in the Otology Rhinology Laryngology International Academic Conference, September 26, 2022, Auditorium Antonianum, Rome, Italy. Paper prepared in fulfillment of the Alfredo T. Ramirez Professorial Chair for 2022.

No man [...] can wear one face to himself and another to the multitude, without finally getting bewildered as to which one may be true. (Nathaniel Hawthorne Scarlet Letter – as seen and pondered by Tony Soprano at Bowdoin College, The Sopranos, Season 1, Episode 5: “College”)The fictitious is a particular and varied source of insight into the everyday world. The idea of seriality—with its variations of the serial, series, seriated—is very much connected to our patterns of entertainment. In this essay, I want to begin the process of testing what values and meanings can be drawn from the idea of seriality into comprehending the play of persona in contemporary culture. From a brief overview of the intersection of persona and seriality as well as a review of the deployment of seriality in popular culture, the article focuses on the character/ person-actor relationship to demonstrate how seriality produces persona. The French term for character—personnage—will be used to underline the clear relations between characterisation, person, and persona which have been developed by the recent work by Lenain and Wiame. Personnage, through its variation on the word person helps push the analysis into fully understanding the particular and integrated configuration between a public persona and the fictional role that an actor inhabits (Heinich).There are several qualities related to persona that allow this movement from the fictional world to the everyday world to be profitable. Persona, in terms of origins, in and of itself implies performance and display. Jung, for instance, calls persona a mask where one is “acting a role” (167); while Goffman considers that performance and roles are at the centre of everyday life and everyday forms and patterns of communication. In recent work, I have use persona to describe how online culture pushes most people to construct a public identity that resembles what celebrities have had to construct for their livelihood for at least the last century (“Persona”; “Self”). My work has expanded to an investigation of how online persona relates to individual agency (“Agency”) and professional postures and positioning (Barbour and Marshall).The fictive constructions then are intensified versions of what persona is addressing: the fabrication of a role for particular directions and ends. Characters or personnages are constructed personas for very directed ends. Their limitation to the study of persona as a dimension of public culture is that they are not real; however, when one thinks of the actor who takes on this fictive identity, there is clearly a relationship between the real personality and that of the character. Moreover, as Nayar’s analysis of highly famous characters that are fictitious reveals, these celebrated characters, such as Harry Potter or Wolverine, sometime take on a public presence in and of themselves. To capture this public movement of a fictional character, Nayar blends the terms celebrity with fiction and calls these semi-public/semi-real entities “celefiction”: the characters are famous, highly visible, and move across media, information, and cultural platforms with ease and speed (18-20). Their celebrity status underlines their power to move outside of their primary text into public discourse and through public spaces—an extra-textual movement which fundamentally defines what a celebrity embodies.Seriality has to be seen as fundamental to a personnage’s power of and extension into the public world. For instance with Harry Potter again, at least some of his recognition is dependent on the linking or seriating the related books and movies. Seriality helps organise our sense of affective connection to our popular culture. The familiarity of some element of repetition is both comforting for audiences and provides at least a sense of guarantee or warranty that they will enjoy the future text as much as they enjoyed the past related text. Seriality, though, also produces a myriad of other effects and affects which provides a useful background to understand its utility in both the understanding of character and its value in investigating contemporary public persona. Etymologically, the words “series” and seriality are from the Latin and refer to “succession” in classical usage and are identified with ancestry and the patterns of identification and linking descendants (Oxford English Dictionary). The original use of the seriality highlights its value in understanding the formation of the constitution of person and persona and how the past and ancestry connect in series to the current or contemporary self. Its current usage, however, has broadened metaphorically outwards to identify anything that is in sequence or linked or joined: it can be a series of lectures and arguments or a related mark of cars manufactured in a manner that are stylistically linked. It has since been deployed to capture the production process of various cultural forms and one of the key origins of this usage came from the 19th century novel. There are many examples where the 19th century novel was sold and presented in serial form that are too numerous to even summarise here. It is useful to use Dickens’ serial production as a defining example of how seriality moved into popular culture and the entertainment industry more broadly. Part of the reason for the sheer length of many of Charles Dickens’ works related to their original distribution as serials. In fact, all his novels were first distributed in chapters in monthly form in magazines or newspapers. A number of related consequences from Dickens’ serialisation are relevant to understanding seriality in entertainment culture more widely (Hayward). First, his novel serialisation established a continuous connection to his readers over years. Thus Dickens’ name itself became synonymous and connected to an international reading public. Second, his use of seriality established a production form that was seen to be more affordable to its audience: seriality has to be understood as a form that is closely connected to economies and markets as cultural commodities kneaded their way into the structure of everyday life. And third, seriality established through repetition not only the author’s name but also the name of the key characters that populated the cultural form. Although not wholly attributable to the serial nature of the delivery, the characters such as Oliver Twist, Ebenezer Scrooge or David Copperfield along with a host of other major and minor players in his many books become integrated into everyday discourse because of their ever-presence and delayed delivery over stories over time (see Allen 78-79). In the same way that newspapers became part of the vernacular of contemporary culture, fictional characters from novels lived for years at a time in the consciousness of this large reading public. The characters or personnages themselves became personalities that through usage became a way of describing other behaviours. One can think of Uriah Heep and his sheer obsequiousness in David Copperfield as a character-type that became part of popular culture thinking and expressing a clear negative sentiment about a personality trait. In the twentieth century, serials became associated much more with book series. One of the more successful serial genres was the murder mystery. It developed what could be described as recognisable personnages that were both fictional and real. Thus, the real Agatha Christie with her consistent and prodigious production of short who-dunnit novels was linked to her Belgian fictional detective Hercule Poirot. Variations of these serial constructions occurred in children’s fiction, the emerging science fiction genre, and westerns with authors and characters rising to related prominence.In a similar vein, early to mid-twentieth century film produced the film serial. In its production and exhibition, the film serial was a déclassé genre in its overt emphasis on the economic quality of seriality. Thus, the film serial was generally a filler genre that was interspersed before and after a feature film in screenings (Dixon). As well as producing a familiarity with characters such as Flash Gordon, it was also instrumental in producing actors with a public profile that grew from this repetition. Flash Gordon was not just a character; he was also the actor Buster Crabbe and, over time, the association became indissoluble for audiences and actor alike. Feature film serials also developed in the first half-century of American cinema in particular with child actors like Shirley Temple, Mickey Rooney and Judy Garland often reprising variations of their previous roles. Seriality more or less became the standard form of delivery of broadcast media for most of the last 70 years and this was driven by the economies of production it developed. Whether the production was news, comedy, or drama, most radio and television forms were and are variation of serials. As well as being the zenith of seriality, television serials have been the most studied form of seriality of all cultural forms and are thus the greatest source of research into what serials actually produced. The classic serial that began on radio and migrated to television was the soap opera. Although most of the long-running soap operas have now disappeared, many have endured for more than 30 years with the American series The Guiding Light lasting 72 years and the British soap Coronation Street now in its 64th year. Australian nighttime soap operas have managed a similar longevity: Neighbours is in its 30th year, while Home and Away is in its 27th year. Much of the analyses of soap operas and serials deals with the narrative and the potential long narrative arcs related to characters and storylines. In contrast to most evening television serials historically, soap operas maintain the continuity from one episode to the next in an unbroken continuity narrative. Evening television serials, such as situation comedies, while maintaining long arcs over their run are episodic in nature: the structure of the story is generally concluded in the given episode with at least partial closure in a manner that is never engaged with in the never-ending soap opera serials.Although there are other cultural forms that deploy seriality in their structures—one can think of comic books and manga as two obvious other connected and highly visible serial sources—online and video games represent the other key media platform of serials in contemporary culture. Once again, a “horizon of expectation” (Jauss and De Man 23) motivates the iteration of new versions of games by the industry. New versions of games are designed to build on gamer loyalties while augmenting the quality and possibilities of the particular game. Game culture and gamers have a different structural relationship to serials which at least Denson and Jahn-Sudmann describe as digital seriality: a new version of a game is also imagined to be technologically more sophisticated in its production values and this transformation of the similitude of game structure with innovation drives the economy of what are often described as “franchises.” New versions of Minecraft as online upgrades or Call of Duty launches draw the literal reinvestment of the gamer. New consoles provide a further push to serialisation of games as they accentuate some transformed quality in gameplay, interaction, or quality of animated graphics. Sports franchises are perhaps the most serialised form of game: to replicate new professional seasons in each major sport, the sports game transforms with a new coterie of players each year.From these various venues, one can see the centrality of seriality in cultural forms. There is no question that one of the dimensions of seriality that transcends these cultural forms is its coordination and intersection with the development of the industrialisation of culture and this understanding of the economic motivation behind series has been explored from some of the earliest analyses of seriality (see Hagedorn; Browne). Also, seriality has been mined extensively in terms of its production of the pleasure of repetition and transformation. The exploration of the popular, whether in studies of readers of romance fiction (Radway), or fans of science fiction television (Tulloch and Jenkins; Jenkins), serials have provided the resource for the exploration of the power of the audience to connect, engage and reconstruct texts.The analysis of the serialisation of character—the production of a public personnage—and its relation to persona surprisingly has been understudied. While certain writers have remarked on the longevity of a certain character, such as Vicky Lord’s 40 year character on the soap opera One Life to Live, and the interesting capacity to maintain both complicated and hidden storylines (de Kosnik), and fan audience studies have looked at the parasocial-familiar relationship that fan and character construct, less has been developed about the relationship of the serial character, the actor and a form of twinned public identity. Seriality does produce a patterning of personnage, a structure of familiarity for the audience, but also a structure of performance for the actor. For instance, in a longitudinal analysis of the character of Fu Manchu, Mayer is able to discern how a patterning of iconic form shapes, replicates, and reiterates the look of Fu Manchu across decades of films (Mayer). Similarly, there has been a certain work on the “taxonomy of character” where the serial character of a television program is analysed in terms of 6 parts: physical traits/appearance; speech patterns, psychological traits/habitual behaviours; interaction with other characters; environment; biography (Pearson quoted in Lotz).From seriality what emerges is a particular kind of “type-casting” where the actor becomes wedded to the specific iteration of the taxonomy of performance. As with other elements related to seriality, serial character performance is also closely aligned to the economic. Previously I have described this economic patterning of performance the “John Wayne Syndrome.” Wayne’s career developed into a form of serial performance where the individual born as Marion Morrison becomes structured into a cultural and economic category that determines the next film role. The economic weight of type also constructs the limits and range of the actor. Type or typage as a form of casting has always been an element of film and theatrical performance; but it is the seriality of performance—the actual construction of a personnage that flows between the fictional and real person—that allows an actor to claim a persona that can be exchanged within the industry. Even 15 years after his death, Wayne remained one of the most popular performers in the United States, his status unrivalled in its close definition of American value that became wedded with a conservative masculinity and politics (Wills).Type and typecasting have an interesting relationship to seriality. From Eisenstein’s original use of the term typage, where the character is chosen to fit into the meaning of the film and the image was placed into its sequence to make that meaning, it generally describes the circumscribing of the actor into their look. As Wojcik’s analysis reveals, typecasting in various periods of theatre and film acting has been seen as something to be fought for by actors (in the 1850s) and actively resisted in Hollywood in 1950 by the Screen Actors Guild in support of more range of roles for each actor. It is also seen as something that leads to cultural stereotypes that can reinforce the racial profiling that has haunted diverse cultures and the dangers of law enforcement for centuries (Wojcik 169-71). Early writers in the study of film acting, emphasised that its difference from theatre was that in film the actor and character converged in terms of connected reality and a physicality: the film actor was less a mask and more a sense of “being”(Kracauer). Cavell’s work suggested film over stage performance allowed an individuality over type to emerge (34). Thompson’s semiotic “commutation” test was another way of assessing the power of the individual “star” actor to be seen as elemental to the construction and meaning of the film role Television produced with regularity character-actors where performance and identity became indissoluble partly because of the sheer repetition and the massive visibility of these seriated performances.One of the most typecast individuals in television history was Leonard Nimoy as Spock in Star Trek: although the original Star Trek series ran for only three seasons, the physical caricature of Spock in the series as a half-Vulcan and half-human made it difficult for the actor Nimoy to exit the role (Laws). Indeed, his famous autobiography riffed on this mis-identity with the forceful but still economically powerful title I am Not Spock in 1975. When Nimoy perceived that his fans thought that he was unhappy in his role as Spock, he published a further tome—I Am Spock—that righted his relationship to his fictional identity and its continued source of roles for the previous 30 years. Although it is usually perceived as quite different in its constitution of a public identity, a very similar structure of persona developed around the American CBS news anchor Walter Cronkite. With his status as anchor confirmed in its power and centrality to American culture in his desk reportage of the assassination and death of President Kennedy in November 1963, Cronkite went on to inhabit a persona as the most trusted man in the United States by the sheer gravitas of hosting the Evening News stripped across every weeknight at 6:30pm for the next 19 years. In contrast to Nimoy, Cronkite became Cronkite the television news anchor, where persona, actor, and professional identity merged—at least in terms of almost all forms of the man’s visibility.From this vantage point of understanding the seriality of character/personnage and how it informs the idea of the actor, I want to provide a longer conclusion about how seriality informs the concept of persona in the contemporary moment. First of all, what this study reveals is the way in which the production of identity is overlaid onto any conception of identity itself. If we can understand persona not in any negative formulation, but rather as a form of productive performance of a public self, then it becomes very useful to see that these very visible public blendings of performance and the actor-self can make sense more generally as to how the public self is produced and constituted. My final and concluding examples will try and elucidate this insight further.In 2013, Netflix launched into the production of original drama with its release of House of Cards. The series itself was remarkable for a number of reasons. First among them, it was positioned as a quality series and clearly connected to the lineage of recent American subscription television programs such as The Sopranos, Six Feet Under, Dexter, Madmen, The Wire, Deadwood, and True Blood among a few others. House of Cards was an Americanised version of a celebrated British mini-series. In the American version, an ambitious party whip, Frank Underwood, manoeuvres with ruthlessness and the calculating support of his wife closer to the presidency and the heart and soul of American power. How the series expressed quality was at least partially in its choice of actors. The role of Frank Underwood was played by the respected film actor Kevin Spacey. His wife, Clare, was played by the equally high profile Robin Warren. Quality was also expressed through the connection of the audience of viewers to an anti-hero: a personnage that was not filled with virtue but moved with Machiavellian acuity towards his objective of ultimate power. This idea of quality emerged in many ways from the successful construction of the character of Tony Soprano by James Gandolfini in the acclaimed HBO television series The Sopranos that reconstructed the very conception of the family in organised crime. Tony Soprano was enacted as complex and conflicted with a sense of right and justice, but embedded in the personnage were psychological tropes and scars, and an understanding of the need for violence to maintain influence power and a perverse but natural sense of order (Martin).The new television serial character now embodied a larger code and coterie of acting: from The Sopranos, there is the underlying sense and sensibility of method acting (see Vineberg; Stanislavski). Gandolfini inhabited the role of Tony Soprano and used the inner and hidden drives and motivations to become the source for the display of the character. Likewise, Spacey inhabits Frank Underwood. In that new habitus of television character, the actor becomes subsumed by the role. Gandolfini becomes both over-determined by the role and his own identity as an actor becomes melded to the role. Kevin Spacey, despite his longer and highly visible history as a film actor is overwhelmed by the televisual role of Frank Underwood. Its serial power, where audiences connect for hours and hours, where the actor commits to weeks and weeks of shoots, and years and years of being the character—a serious character with emotional depth, with psychological motivation that rivals the most visceral of film roles—transforms the actor into a blended public person and the related personnage.This blend of fictional and public life is complex as much for the producing actor as it is for the audience that makes the habitus real. What Kevin Spacey/Frank Underwood inhabit is a blended persona, whose power is dependent on the constructed identity that is at source the actor’s production as much as any institutional form or any writer or director connected to making House of Cards “real.” There is no question that this serial public identity will be difficult for Kevin Spacey to disentangle when the series ends; in many ways it will be an elemental part of his continuing public identity. This is the economic power and risk of seriality.One can see similar blendings in the persona in popular music and its own form of contemporary seriality in performance. For example, Eminem is a stage name for a person sometimes called Marshall Mathers; but Eminem takes this a step further and produces beyond a character in its integration of the personal—a real personnage, Slim Shady, to inhabit his music and its stories. To further complexify this construction, Eminem relies on the production of his stories with elements that appear to be from his everyday life (Dawkins). His characterisations because of the emotional depth he inhabits through his rapped stories betray a connection to his own psychological state. Following in the history of popular music performance where the singer-songwriter’s work is seen by all to present a version of the public self that is closer emotionally to the private self, we once again see how the seriality of performance begins to produce a blended public persona. Rap music has inherited this seriality of produced identity from twentieth century icons of the singer/songwriter and its display of the public/private self—in reverse order from grunge to punk, from folk to blues.Finally, it is worthwhile to think of online culture in similar ways in the production of public personas. Seriality is elemental to online culture. Social media encourage the production of public identities through forms of repetition of that identity. In order to establish a public profile, social media users establish an identity with some consistency over time. The everydayness in the production of the public self online thus resembles the production and performance of seriality in fiction. Professional social media sites such as LinkedIn encourage the consistency of public identity and this is very important in understanding the new versions of the public self that are deployed in contemporary culture. However, much like the new psychological depth that is part of the meaning of serial characters such as Frank Underwood in House of Cards, Slim Shady in Eminem, or Tony Soprano in The Sopranos, social media seriality also encourages greater revelations of the private self via Instagram and Facebook walls and images. We are collectively reconstituted as personas online, seriated by the continuing presence of our online sites and regularly drawn to reveal more and greater depths of our character. In other words, the online persona resembles the new depth of the quality television serial personnage with elaborate arcs and great complexity. Seriality in our public identity is also uncovered in the production of our game avatars where, in order to develop trust and connection to friends in online settings, we maintain our identity and our patterns of gameplay. At the core of this online identity is a desire for visibility, and we are drawn to be “picked up” and shared in some repeatable form across what we each perceive as a meaningful dimension of culture. Through the circulation of viral images, texts, and videos we engage in a circulation and repetition of meaning that feeds back into the constancy and value of an online identity. Through memes we replicate and seriate content that at some level seriates personas in terms of humour, connection and value.Seriality is central to understanding the formation of our masks of public identity and is at least one valuable analytical way to understand the development of the contemporary persona. This essay represents the first foray in thinking through the relationship between seriality and persona.ReferencesBarbour, Kim, and P. David Marshall. “The Academic Online Constructing Persona.” First Monday 17.9 (2012).Browne, Nick. “The Political Economy of the (Super)Text.” Quarterly Review of Film Studies 9.3 (1984): 174-82. Cavell, Stanley. “Reflections on the Ontology of Film.” Movie Acting: The Film Reader. Ed. Wojcik and Pamela Robertson. 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Seeing Stars: Spectacle, Society, and Celebrity Culture. New Delhi; Thousand Oaks, California: Sage Publications, 2009.Nimoy, Leonard. I Am Not Spock. Milbrae, California: Celestial Arts, 1975.Nimoy, Leonard. I Am Spock. 1st ed. New York: Hyperion, 1995.Radway, Janice A. Reading the Romance: Women, Patriarchy, and Popular Literature. Chapel Hill: University of North Carolina Press, 1984.Stanislavski, Constantin. Creating a Role. New York: Routledge, 1989 (1961).Thompson, John O. “Screen Acting and the Commutation Test.” Movie Acting: The Film Reader. Ed. Pamela Robertson Wojcik. London: Routledge, 2004 (1978). 37-48.Tulloch, John, and Henry Jenkins. Science Fiction Audiences: Watching Doctor Who and Star Trek. London; New York: Routledge, 1995.Vineberg, Steve. Method Actors: Three Generations of an American Acting Style. New York; Toronto: Schirmer Books, 1991.Wills, Garry. John Wayne’s America: The Politics of Celebrity. 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Refereed publications (also known as peer-reviewed) are the currency of academia, yet many PhD theses in Australia result in only one or two such papers. Typically, a doctoral thesis requires the candidate to present (and pass) a public Confirmation Seminar, around nine to twelve months into candidacy, in which a panel of the candidate’s supervisors and invited experts adjudicate upon whether the work is likely to continue and ultimately succeed in the goal of a coherent and original contribution to knowledge. A Final Seminar, also public and sometimes involving the traditional viva voce or oral defence of the thesis, is presented two or three months before approval is given to send the 80,000 to 100,000 word tome off for external examination. And that soul-destroying or elation-releasing examiner’s verdict can be many months in the delivery: a limbo-like period during which the candidate’s status as a student is ended and her or his receipt of any scholarship or funding guerdon is terminated with perfunctory speed. This is the only time most students spend seriously writing up their research for publication although, naturally, many are more involved in job hunting as they pin their hopes on passing the thesis examination.There is, however, a slightly more palatable alternative to this nail-biting process of the traditional PhD, and that is the PhD by Published Papers (also known as PhD by Publications or PhD by Published Works). The form of my own soon-to-be-submitted thesis, it permits the submission for examination of a collection of papers that have been refereed and accepted (or are in the process of being refereed) for publication in academic journals or books. Apart from the obvious benefits in getting published early in one’s (hopefully) burgeoning academic career, it also takes away a lot of the stress come final submission time. After all, I try to assure myself, the thesis examiners can’t really discredit the process of double-blind, peer-review the bulk of the thesis has already undergone: their job is to examine how well I’ve unified the papers into a cohesive thesis … right? But perhaps they should at least be wary, because, unfortunately, the requirements for this kind of PhD vary considerably from institution to institution and there have been some cases where the submitted work is of questionable quality compared to that produced by graduates from more demanding universities. Hence, this paper argues that in my subject area of interest—film and television studies—there is a huge range in the set requirements for doctorates, from universities that award the degree to film artists for prior published work that has undergone little or no academic scrutiny and has involved little or no on-campus participation to at least three Australian universities that require candidates be enrolled for a minimum period of full-time study and only submit scholarly work generated and published (or submitted for publication) during candidature. I would also suggest that uncertainty about where a graduate’s work rests on this continuum risks confusing a hard-won PhD by Published Papers with the sometimes risible honorary doctorate. Let’s begin by dredging the depths of those murky, quasi-academic waters to examine the occasionally less-than-salubrious honorary doctorate. The conferring of this degree is generally a recognition of an individual’s body of (usually published) work but is often conferred for contributions to knowledge or society in general that are not even remotely academic. The honorary doctorate does not usually carry with it the right to use the title “Dr” (although many self-aggrandising recipients in the non-academic world flout this unwritten code of conduct, and, indeed, Monash University’s Monash Magazine had no hesitation in describing its 2008 recipient, musician, screenwriter, and art-school-dropout Nick Cave, as “Dr Cave” (O’Loughlin)). Some shady universities even offer such degrees for sale or ‘donation’ and thus do great damage to that institution’s credibility as well as to the credibility of the degree itself. Such overseas “diploma mills”—including Ashwood University, Belford University, Glendale University and Suffield University—are identified by their advertising of “Life Experience Degrees,” for which a curriculum vitae outlining the prospective graduand’s oeuvre is accepted on face value as long as their credit cards are not rejected. An aspiring screen auteur simply specifies film and television as their major and before you can shout “Cut!” there’s a degree in the mail. Most of these pseudo-universities are not based in Australia but are perfectly happy to confer their ‘titles’ to any well-heeled, vanity-driven Australians capable of completing the online form. Nevertheless, many academics fear a similarly disreputable marketplace might develop here, and Norfolk Island-based Greenwich University presents a particularly illuminating example. Previously empowered by an Act of Parliament consented to by Senator Ian Macdonald, the then Minister for Territories, this “university” had the legal right to confer honorary degrees from 1998. The Act was eventually overridden by legislation passed in 2002, after a concerted effort by the Australian Universities Quality Agency Ltd. and the Australian Vice-Chancellors’ Committee to force the accreditation requirements of the Australian Qualifications Framework upon the institution in question, thus preventing it from making degrees available for purchase over the Internet. Greenwich University did not seek re-approval and soon relocated to its original home of Hawaii (Brown). But even real universities flounder in similarly muddy waters when, unsolicited, they make dubious decisions to grant degrees to individuals they hold in high esteem. Although meaning well by not courting pecuniary gain, they nevertheless invite criticism over their choice of recipient for their honoris causa, despite the decision usually only being reached after a process of debate and discussion by university committees. Often people are rewarded, it seems, as much for their fame as for their achievements or publications. One such example of a celebrity who has had his onscreen renown recognised by an honorary doctorate is film and television actor/comedian Billy Connolly who was awarded an Honorary Doctor of Letters by The University of Glasgow in 2006, prompting Stuart Jeffries to complain that “something has gone terribly wrong in British academia” (Jeffries). Eileen McNamara also bemoans the levels to which some institutions will sink to in search of media attention and exposure, when she writes of St Andrews University in Scotland conferring an honorary doctorate to film actor and producer, Michael Douglas: “What was designed to acknowledge intellectual achievement has devolved into a publicity grab with universities competing for celebrity honorees” (McNamara). Fame as an actor (and the list gets even weirder when the scope of enquiry is widened beyond the field of film and television), seems to be an achievement worth recognising with an honorary doctorate, according to some universities, and this kind of discredit is best avoided by Australian institutions of higher learning if they are to maintain credibility. Certainly, universities down under would do well to follow elsewhere than in the footprints of Long Island University’s Southampton College. Perhaps the height of academic prostitution of parchments for the attention of mass media occurred when in 1996 this US school bestowed an Honorary Doctorate of Amphibious Letters upon that mop-like puppet of film and television fame known as the “muppet,” Kermit the Frog. Indeed, this polystyrene and cloth creation with an anonymous hand operating its mouth had its acceptance speech duly published (see “Kermit’s Acceptance Speech”) and the Long Island University’s Southampton College received much valuable press. After all, any publicity is good publicity. Or perhaps this furry frog’s honorary degree was a cynical stunt meant to highlight the ridiculousness of the practice? In 1986 a similar example, much closer to my own home, occurred when in anticipation and condemnation of the conferral of an honorary doctorate upon Prince Philip by Monash University in Melbourne, the “Members of the Monash Association of Students had earlier given a 21-month-old Chihuahua an honorary science degree” (Jeffries), effectively suggesting that the honorary doctorate is, in fact, a dog of a degree. On a more serious note, there have been honorary doctorates conferred upon far more worthy recipients in the field of film and television by some Australian universities. Indigenous film-maker Tracey Moffatt was awarded an honorary doctorate by Griffith University in November of 2004. Moffatt was a graduate of the Griffith University’s film school and had an excellent body of work including the films Night Cries: A Rural Tragedy (1990) and beDevil (1993). Acclaimed playwright and screenwriter David Williamson was presented with an Honorary Doctorate of Letters by The University of Queensland in December of 2004. His work had previously picked up four Australian Film Institute awards for best screenplay. An Honorary Doctorate of Visual and Performing Arts was given to film director Fred Schepisi AO by The University of Melbourne in May of 2006. His films had also been earlier recognised with Australian Film Institute awards as well as the Golden Globe Best Miniseries or Television Movie award for Empire Falls in 2006. Director George Miller was crowned with an Honorary Doctorate in Film from the Australian Film, Television, and Radio School in April 2007, although he already had a medical doctor’s testamur on his wall. In May of this year, filmmaker George Gittoes, a fine arts dropout from The University of Sydney, received an honorary doctorate by The University of New South Wales. His documentaries, Soundtrack to War (2005) and Rampage (2006), screened at the Sydney and Berlin film festivals, and he has been employed by the Australian Government as an official war artist. Interestingly, the high quality screen work recognised by these Australian universities may have earned the recipients ‘real’ PhDs had they sought the qualification. Many of these film artists could have just as easily submitted their work for the degree of PhD by Published Papers at several universities that accept prior work in lieu of an original exegesis, and where a film is equated with a book or journal article. But such universities still invite comparisons of their PhDs by Published Papers with honorary doctorates due to rather too-easy-to-meet criteria. The privately funded Bond University, for example, recommends a minimum full-time enrolment of just three months and certainly seems more lax in its regulations than other Antipodean institution: a healthy curriculum vitae and payment of the prescribed fee (currently AUD$24,500 per annum) are the only requirements. Restricting my enquiries once again to the field of my own research, film and television, I note that Dr. Ingo Petzke achieved his 2004 PhD by Published Works based upon films produced in Germany well before enrolling at Bond, contextualized within a discussion of the history of avant-garde film-making in that country. Might not a cynic enquire as to how this PhD significantly differs from an honorary doctorate? Although Petzke undoubtedly paid his fees and met all of Bond’s requirements for his thesis entitled Slow Motion: Thirty Years in Film, one cannot criticise that cynic for wondering if Petzke’s films are indeed equivalent to a collection of refereed papers. It should be noted that Bond is not alone when it comes to awarding candidates the PhD by Published Papers for work published or screened in the distant past. Although yet to grant it in the area of film or television, Swinburne University of Technology (SUT) is an institution that distinctly specifies its PhD by Publications is to be awarded for “research which has been carried out prior to admission to candidature” (8). Similarly, the Griffith Law School states: “The PhD (by publications) is awarded to established researchers who have an international reputation based on already published works” (1). It appears that Bond is no solitary voice in the academic wilderness, for SUT and the Griffith Law School also apparently consider the usual milestones of Confirmation and Final Seminars to be unnecessary if the so-called candidate is already well published. Like Bond, Griffith University (GU) is prepared to consider a collection of films to be equivalent to a number of refereed papers. Dr Ian Lang’s 2002 PhD (by Publication) thesis entitled Conditional Truths: Remapping Paths To Documentary ‘Independence’ contains not refereed, scholarly articles but the following videos: Wheels Across the Himalaya (1981); Yallambee, People of Hope (1986); This Is What I Call Living (1988); The Art of Place: Hanoi Brisbane Art Exchange (1995); and Millennium Shift: The Search for New World Art (1997). While this is a most impressive body of work, and is well unified by appropriate discussion within the thesis, the cynic who raised eyebrows at Petzke’s thesis might also be questioning this thesis: Dr Lang’s videos all preceded enrolment at GU and none have been refereed or acknowledged with major prizes. Certainly, the act of releasing a film for distribution has much in common with book publishing, but should these videos be considered to be on a par with academic papers published in, say, the prestigious and demanding journal Screen? While recognition at awards ceremonies might arguably correlate with peer review there is still the question as to how scholarly a film actually is. Of course, documentary films such as those in Lang’s thesis can be shown to be addressing gaps in the literature, as is the expectation of any research paper, but the onus remains on the author/film-maker to demonstrate this via a detailed contextual review and a well-written, erudite argument that unifies the works into a cohesive thesis. This Lang has done, to the extent that suspicious cynic might wonder why he chose not to present his work for a standard PhD award. Another issue unaddressed by most institutions is the possibility that the publications have been self-refereed or refereed by the candidate’s editorial colleagues in a case wherein the papers appear in a book the candidate has edited or co-edited. Dr Gillian Swanson’s 2004 GU thesis Towards a Cultural History of Private Life: Sexual Character, Consuming Practices and Cultural Knowledge, which addresses amongst many other cultural artefacts the film Lawrence of Arabia (David Lean 1962), has nine publications: five of which come from two books she co-edited, Nationalising Femininity: Culture, Sexuality and Cinema in Britain in World War Two, (Gledhill and Swanson 1996) and Deciphering Culture: Ordinary Curiosities and Subjective Narratives (Crisp et al 2000). While few would dispute the quality of Swanson’s work, the persistent cynic might wonder if these five papers really qualify as refereed publications. The tacit understanding of a refereed publication is that it is blind reviewed i.e. the contributor’s name is removed from the document. Such a system is used to prevent bias and favouritism but this level of anonymity might be absent when the contributor to a book is also one of the book’s editors. Of course, Dr Swanson probably took great care to distance herself from the refereeing process undertaken by her co-editors, but without an inbuilt check, allegations of cronyism from unfriendly cynics may well result. A related factor in making comparisons of different university’s PhDs by Published Papers is the requirements different universities have about the standard of the journal the paper is published in. It used to be a simple matter in Australia: the government’s Department of Education, Science and Training (DEST) held a Register of Refereed Journals. If your benefactor in disseminating your work was on the list, your publications were of near-unquestionable quality. Not any more: DEST will no longer accept nominations for listing on the Register and will not undertake to rule on whether a particular journal article meets the HERDC [Higher Education Research Data Collection] requirements for inclusion in publication counts. HEPs [Higher Education Providers] have always had the discretion to determine if a publication produced in a journal meets the requirements for inclusion in the HERDC regardless of whether or not the journal was included on the Register of Refereed Journals. As stated in the HERDC specifications, the Register is not an exhaustive list of all journals which satisfy the peer-review requirements (DEST). The last listing for the DEST Register of Refereed Journals was the 3rd of February 2006, making way for a new tiered list of academic journals, which is currently under review in the Australian tertiary education sector (see discussion of this development in the Redden and Mitchell articles in this issue). In the interim, some university faculties created their own rankings of journals, but not the Faculty of Creative Industries at the Queensland University of Technology (QUT) where I am studying for my PhD by Published Papers. Although QUT does not have a list of ranked journals for a candidate to submit papers to, it is otherwise quite strict in its requirements. The QUT University Regulations state, “Papers submitted as a PhD thesis must be closely related in terms of subject matter and form a cohesive research narrative” (QUT PhD regulation 14.1.2). Thus there is the requirement at QUT that apart from the usual introduction, methodology and literature review, an argument must be made as to how the papers present a sustained research project via “an overarching discussion of the main features linking the publications” (14.2.12). It is also therein stated that it should be an “account of research progress linking the research papers” (4.2.6). In other words, a unifying essay must make an argument for consideration of the sometimes diversely published papers as a cohesive body of work, undertaken in a deliberate journey of research. In my own case, an aural auteur analysis of sound in the films of Rolf de Heer, I argue that my published papers (eight in total) represent a journey from genre analysis (one paper) to standard auteur analysis (three papers) to an argument that sound should be considered in auteur analysis (one paper) to the major innovation of the thesis, aural auteur analysis (three papers). It should also be noted that unlike Bond, GU or SUT, the QUT regulations for the standard PhD still apply: a Confirmation Seminar, Final Seminar and a minimum two years of full-time enrolment (with a minimum of three months residency in Brisbane) are all compulsory. Such milestones and sine qua non ensure the candidate’s academic progress and intellectual development such that she or he is able to confidently engage in meaningful quodlibets regarding the thesis’s topic. Another interesting and significant feature of the QUT guidelines for this type of degree is the edict that papers submitted must be “published, accepted or submitted during the period of candidature” (14.1.1). Similarly, the University of Canberra (UC) states “The articles or other published material must be prepared during the period of candidature” (10). Likewise, Edith Cowan University (ECU) will confer its PhD by Publications to those candidates whose thesis consists of “only papers published in refereed scholarly media during the period of enrolment” (2). In other words, one cannot simply front up to ECU, QUT, or UC with a résumé of articles or films published over a lifetime of writing or film-making and ask for a PhD by Published Papers. Publications of the candidate prepared prior to commencement of candidature are simply not acceptable at these institutions and such PhDs by Published Papers from QUT, UC and ECU are entirely different to those offered by Bond, GU and SUT. Furthermore, without a requirement for a substantial period of enrolment and residency, recipients of PhDs by Published Papers from Bond, GU, or SUT are unlikely to have participated significantly in the research environment of their relevant faculty and peers. Such newly minted doctors may be as unfamiliar with the campus and its research activities as the recipient of an honorary doctorate usually is, as he or she poses for the media’s cameras en route to the glamorous awards ceremony. Much of my argument in this paper is built upon the assumption that the process of refereeing a paper (or for that matter, a film) guarantees a high level of academic rigour, but I confess that this premise is patently naïve, if not actually flawed. Refereeing can result in the rejection of new ideas that conflict with the established opinions of the referees. Interdisciplinary collaboration can be impeded and the lack of referee’s accountability is a potential problem, too. It can also be no less nail-biting a process than the examination of a finished thesis, given that some journals take over a year to complete the refereeing process, and some journal’s editorial committees have recognised this shortcoming. Despite being a mainstay of its editorial approach since 1869, the prestigious science journal, Nature, which only publishes about 7% of its submissions, has led the way with regard to varying the procedure of refereeing, implementing in 2006 a four-month trial period of ‘Open Peer Review’. Their website states, Authors could choose to have their submissions posted on a preprint server for open comments, in parallel with the conventional peer review process. Anyone in the field could then post comments, provided they were prepared to identify themselves. Once the usual confidential peer review process is complete, the public ‘open peer review’ process was closed and the editors made their decision about publication with the help of all reports and comments (Campbell). Unfortunately, the experiment was unpopular with both authors and online peer reviewers. What the Nature experiment does demonstrate, however, is that the traditional process of blind refereeing is not yet perfected and can possibly evolve into something less problematic in the future. Until then, refereeing continues to be the best system there is for applying structured academic scrutiny to submitted papers. With the reforms of the higher education sector, including forced mergers of universities and colleges of advanced education and the re-introduction of university fees (carried out under the aegis of John Dawkins, Minister for Employment, Education and Training from 1987 to 1991), and the subsequent rationing of monies according to research dividends (calculated according to numbers of research degree conferrals and publications), there has been a veritable explosion in the number of institutions offering PhDs in Australia. But the general public may not always be capable of differentiating between legitimately accredited programs and diploma mills, given that the requirements for the first differ substantially. From relatively easily obtainable PhDs by Published Papers at Bond, GU and SUT to more rigorous requirements at ECU, QUT and UC, there is undoubtedly a huge range in the demands of degrees that recognise a candidate’s published body of work. The cynical reader may assume that with this paper I am simply trying to shore up my own forthcoming graduation with a PhD by Published papers from potential criticisms that it is on par with a ‘purchased’ doctorate. Perhaps they are right, for this is a new degree in QUT’s Creative Industries faculty and has only been awarded to one other candidate (Dr Marcus Foth for his 2006 thesis entitled Towards a Design Methodology to Support Social Networks of Residents in Inner-City Apartment Buildings). But I believe QUT is setting a benchmark, along with ECU and UC, to which other universities should aspire. In conclusion, I believe further efforts should be undertaken to heighten the differences in status between PhDs by Published Papers generated during enrolment, PhDs by Published Papers generated before enrolment and honorary doctorates awarded for non-academic published work. Failure to do so courts cynical comparison of all PhD by Published Papers with unearnt doctorates bought from Internet shysters. References Brown, George. “Protecting Australia’s Higher Education System: A Proactive Versus Reactive Approach in Review (1999–2004).” Proceedings of the Australian Universities Quality Forum 2004. Australian Universities Quality Agency, 2004. 11 June 2008 ‹http://www.auqa.edu.au/auqf/2004/program/papers/Brown.pdf>. Campbell, Philip. “Nature Peer Review Trial and Debate.” Nature: International Weekly Journal of Science. December 2006. 11 June 2008 ‹http://www.nature.com/nature/peerreview/> Crisp, Jane, Kay Ferres, and Gillian Swanson, eds. Deciphering Culture: Ordinary Curiosities and Subjective Narratives. London: Routledge, 2000. Department of Education, Science and Training (DEST). “Closed—Register of Refereed Journals.” Higher Education Research Data Collection, 2008. 11 June 2008 ‹http://www.dest.gov.au/sectors/research_sector/online_forms_services/ higher_education_research_data_ collection.htm>. Edith Cowan University. “Policy Content.” Postgraduate Research: Thesis by Publication, 2003. 11 June 2008 ‹http://www.ecu.edu.au/GPPS/policies_db/tmp/ac063.pdf>. Gledhill, Christine, and Gillian Swanson, eds. Nationalising Femininity: Culture, Sexuality and Cinema in Britain in World War Two. Manchester: Manchester UP, 1996. Griffith Law School, Griffith University. Handbook for Research Higher Degree Students. 24 March 2004. 11 June 2008 ‹http://www.griffith.edu.au/centre/slrc/pdf/rhdhandbook.pdf>. Jeffries, Stuart. “I’m a celebrity, get me an honorary degree!” The Guardian 6 July 2006. 11 June 2008 ‹http://education.guardian.co.uk/higher/comment/story/0,,1813525,00.html>. Kermit the Frog. “Kermit’s Commencement Address at Southampton Graduate Campus.” Long Island University News 19 May 1996. 11 June 2008 ‹http://www.southampton.liu.edu/news/commence/1996/kermit.htm>. McNamara, Eileen. “Honorary senselessness.” The Boston Globe 7 May 2006. ‹http://www. boston.com/news/local/articles/2006/05/07/honorary_senselessness/>. O’Loughlin, Shaunnagh. “Doctor Cave.” Monash Magazine 21 (May 2008). 13 Aug. 2008 ‹http://www.monash.edu.au/pubs/monmag/issue21-2008/alumni/cave.html>. Queensland University of Technology. “Presentation of PhD Theses by Published Papers.” Queensland University of Technology Doctor of Philosophy Regulations (IF49). 12 Oct. 2007. 11 June 2008 ‹http://www.mopp.qut.edu.au/Appendix/appendix09.jsp#14%20Presentation %20of%20PhD%20Theses>. Swinburne University of Technology. Research Higher Degrees and Policies. 14 Nov. 2007. 11 June 2008 ‹http://www.swinburne.edu.au/corporate/registrar/ppd/docs/RHDpolicy& procedure.pdf>. University of Canberra. Higher Degrees by Research: Policy and Procedures (The Gold Book). 7.3.3.27 (a). 15 Nov. 2004. 11 June 2008 ‹http://www.canberra.edu.au/research/attachments/ goldbook/Pt207_AB20approved3220arp07.pdf>.

I sat alone on the beach under the shade of a big umbrella. My husband, Bill, and our three children were in the condo taking a break from the Florida sunshine. Dreamily, I gazed at the vast Gulf of Mexico, the brilliant blue sky stretching endlessly above. I was sitting about 50 feet from the surf, but I couldn't actually see the waves hitting the beach; I was almost blind. It was a windy day in late May and I loved feeling the ocean breeze sweeping over me. I imagined I could hear the waves crashing onto the surf, but the sound was only a memory. I was totally deaf. Although I had a cochlear implant and could hear the waves, the cry of sea gulls, and many other sounds with the technology, I wasn't wearing it at the moment and everything I heard was in my mind. As a child, my understanding of speech was better and my vision was clearer. My diagnosis was optic atrophy at age 5 and my vision gradually degenerated over the years. For unknown reasons, nerve damage caused hearing loss and during my teens, my hearing grew worse and worse until by the time I was ready for college, I was profoundly deaf. I chose to attend Gallaudet University because my high school teachers and my parents felt I would receive better services as a deaf and blind student. I feel it was a very good decision; when I entered Gallaudet, it was like entering a new and exhilarating world. Before attending Gallaudet, while I struggled to cope with hearing loss combined with severely low vision, my world grew smaller and smaller, not being able to communicate efficiently with others. At Gallaudet, I suddenly found I could communicate with almost anybody I met on campus using sign language. Thus, my self-confidence and independence grew as I proceeded to get a college education.It wasn't an easy route to follow. I didn't know Braille at the time and depended on using a CCTV (closed captioned television) electronic aid which magnified text, enabling me to read all my college books. I also relied on the assistance of a class aid who interpreted all my teachers' lectures and class discussions because I was unable to see people's signing unless they signed right in front of my face. It was slow going and often frustrating, trying to keep involved socially and keeping up with my coursework but when I was 13 years old, my vision specialist teacher who had worked with me from 5th grade until I graduated from high school, wrote a note for me saying, "Anything worthwhile seldom comes easy." The phrase stuck in my mind and I tried to follow this philosophy. In 1989 after 7 years of persistence, I graduated with a Bachelor's of Arts degree in psychology. With the B.A. in hand and having developed good communication skills with deaf and deaf-blind people using sign language and ASL (American Sign Language), I was ready to face the world. But I wasn't exactly ready; I knew I wanted a professional job working with deaf-blind people and the way to get there was to earn a master's degree. I applied for admission into Gallaudet's graduate school and was accepted into the vocational rehabilitation counselling program. While I thoroughly enjoyed graduate school experience, I got to work with my class mates one-on-one more often and there were a lot more hands-on activities, it became obvious to me that I wasn't prepared for graduate school. I needed to learn Braille and how to use Braille technology; my vision had worsened a lot since starting college. In addition, I needed a break from school and needed to gain experience in the working world. After completing one and a half years and earning 15 credit hours in the master's program, I left Gallaudet and found a job in Baltimore, Maryland.The job was with a new program for adults who were visually and hearing impaired and mentally disabled. My job was assisting the clients with independent living and work related skills. Most of the other staff were deaf, communicating via ASL. By then, I was skilled using tactile signing, putting my hand on the back of the signer's hand to follow movements by touch, and I made friends with co-workers. I felt grown up and independent working full-time, living in my own apartment, using the subway train and bus to travel to and from work. I didn't have any serious problems living on my own. There was a supermarket up the road to which I could walk or ride a bus. But I needed a taxi ride back to the apartment when I had more groceries than I could carry. I would leave a sign I made out of cardboard and wrote my address in big black numbers, on my apartment door to help the driver find my place. I used a white cane and upon moving to Baltimore, an Orientation and Mobility (O and M) teacher who worked with blind people, showing them how to travel in the city, taught me the route to my work place using the subway and bus. Thus, I was independent and knew my way to work as well as to a nearby shopping mall. One day as I stood on the subway station platform holding my white cane, waiting for my train, the opposite train pulled in. As I stood watching passengers hurrying to board, knowing my train would arrive soon on the other side, a woman ran up to me and started pulling my arm. I handed her my notebook and black marker I used for communicating with people in the public, telling her I couldn't hear and would she please write in large print? She frantically scribbled something, but I couldn't read the note. She then gave me back the pen and pad, grabbed my arm again and started pulling me towards the train. I refused to budge, gesturing towards the opposite tracks, clearly indicating I was waiting for the other train. Finally, she let go, dashed into the train before the doors closed. I watched the train pull away, sadly reflecting that some people who wanted to help, just didn't understand how to approach disabled people. As a deaf-blind traveller, it was my duty to help educate the general public how to assist disabled persons in a humane way. After I established my new life for a few months, Bill was offered a position in the same program and moved to Baltimore to join me. He had worked at the Helen Keller National Centre in New York where I met him while doing a summer internship there three years before. I was thrilled when he got the job working beside me and we got to know each other on a daily basis. We had been dating since we met although I was in college and he was working and living in New York and then Cleveland, Ohio. Bill being hearing and sighted, was skilled in sign language and communication techniques with deaf-blind people. He had a wonderful attitude towards disabled people and made me feel like a normal person who was capable of doing things. We shared a lot and were very comfortable with each other. After nearly six months together in Baltimore, we married in May 1992, several weeks before my 28th birthday.After our first year of marriage living in Maryland, Bill and I moved to Little Rock, Arkansas. We wanted to live closer to my family and parents, Ron and Judy Cummings, who lived in Poplar Bluff, Missouri, 176 miles north of Little Rock. I wanted to go back to school and entered the deaf education program at the University of Arkansas at Little Rock with the goal of becoming a teacher for deaf-blind students. I never dreamed I would have a deaf-blind child of my own one day. My vision and hearing loss were caused by nerve damage and no one else in my family nor Bill's had a similar disability.I was pregnant with our first child when I entered UALR. In spite of my growing belly, I enjoyed the teacher training experience. I worked with a deaf-blind 12-year-old student and her teacher at the Arkansas School for the Deaf; observed two energetic four-year-olds in the pre-school program. But when my son, Joe was born in June 1994, my world changed once again. School became less important and motherhood became the ultimate. As a deaf-blind person, I wanted to be the best mom within my abilities.I decided that establishing good communication with my child was an important aspect of being a deaf-blind mom. Bill was in full agreement and we would set Joe on the kitchen table in his infant carrier, reciting together in sign language, "The three Bears". I could see Joe's tiny fists and feet wave excitedly in the air as he watched us signing children's stories. I would encourage Joe to hold my fingers while I signed to him, trying to establish a tactile signing relationship. But he was almost two years old when he finally understood that he needed to sign into my hands. We were sitting at the table and I had a bag of cookies. I refused to give him one until he made the sign for "cookie" in my hand. I quickly rewarded him with a cookie and he got three or four each time he made the sign in my hand. Today at 16, Joe is an expert finger speller and can effectively communicate with me and his younger deaf-blind brother, Ben.When Joe was two and a half, I decided to explore a cochlear implant. It was 1996 and we were living in Poplar Bluff by then. My cousin, who was studying audiology, told me that people using cochlear implants were able to understand sound so well they didn't need good vision. I made an appointment with the St. Louis cochlear implant program and after being evaluated, I decided to go ahead. I am glad I have a cochlear implant. After months of practice I learned to use the new sound and was eventually able to understand many environmental sounds. I never regained the ability of understanding speech, though, but I could hear people's voices very clearly, the sound of laughter, birds singing, and many more. Being able to hear my children's voices is especially wonderful, even when they get noisy and I get a headache. That fall I went to Leader Dogs School for the Blind (LDSB) where I met Milo, a large yellow Labrador retriever. At LDSB I learned how to care for and work with a dog guide. Having Milo as my companion and guide was like stepping into another new and wonderful world of independence. With Milo, I could walk briskly and feel secure. Milo was a big help as a deaf-blind mom, too. With Milo's guiding help, it was wonderful following my children while they rode tricycles or bikes and the whole family enjoyed going out for walks together. Our second son, Ben, was born in February 1999. He was a perfectly healthy little boy and Bill and I were looking forward to raising two sons. Joe was four and a half years old when Ben was born and was fascinated in his new brother. But when Ben was 5 months old, he was diagnosed with Langerhans Cell Histiocytosis (LCH), a rare childhood disease and in some cases, fatal. It was a long, scary road we followed as Ben received treatment at the children's hospital in St. Louis which involved making the 150 mile trip almost weekly for chemotherapy and doctor check-ups. Through it all, Ben was a happy little boy, in spite of the terrible rash that affected his scalp and diaper area, a symptom of LCH. Bill and I knew that we had to do everything possible to help Ben. When he was a year old, his condition seemed stable enough for me to feel comfortable leaving my family for two months to study Braille and learn new technology skills at a program in Kansas City. My vision had deteriorated to a point where I could no longer use a CCTV.Bill's mom, Marie Reid, who lived in Cleveland, Ohio, made a special trip to stay at our home in Poplar Bluff to help Bill with the boys while I was gone. I was successful at the program, learning Braille, making a change from magnification to Braille technology. Upon returning home, I began looking for a job and found employment as a deaf-blind specialist in a new project in Mississippi. The job was in Tupelo and we moved to northern Mississippi, settling into a new life. We transferred Ben's treatment to St. Judes Children's hospital located in Memphis, 94 miles west of Tupelo. I went to work and Bill stayed home with the boys, which worked well. When Ben had to go to St. Judes every three weeks for chemotherapy, Bill was able to drive him. The treatment was successful, the rash had disappeared and there were no traces of LCH in Ben's blood tests. But when he was almost 3 years old, he was diagnosed with optic atrophy, the same eye disease I suffered from and an audiologist detected signs of inner ear hearing loss.Shocked at the news that our little son would grow up legally blind and perhaps become deaf, Bill and I had to rethink our future. We knew we wanted Ben to have a good life and as a deaf-blind child, he needed quality services. We chose to move to Pittsburgh, Pennsylvania because I knew there were good services for deaf-blind people and I could function independently as a stay-home mom. In addition, Cleveland, Ohio, where Marie Reid and several of Bill's siblings lived, was a two hour's drive from Pittsburgh and living near family was important to us. With regret, I left my job opportunity and new friends and we re-located to Pittsburgh. We lived on a quiet street near Squirrel Hill and enrolled Joe into a near-by Catholic school. Ben received excellent early intervention services through the Pittsburgh public school, beginning Braille, using a white cane and tactile signing. The Pennsylvania services for the blind generously purchased a wonderful computer system and Braille display for me to use at home. I was able to communicate with Joe's and Ben's teachers and other contacts using e-mail. Ben's Braille teacher provided us with several print/Braille books which I read to the boys while Ben touched the tactile pictures. I made friends in the deaf and deaf-blind community and our family attended social events. Besides the social benefits of a deaf community, Pittsburgh offered a wonderful interpreting service and I was able to take Ben to doctor appointments knowing an interpreter would meet me at the hospital to assist with communication. I also found people who were willing to help me as volunteer SSPs (support Service Providers), persons whose role is to assist a deaf-blind person in any way, such as shopping, going to the bank, etc. Thus, I was able to function quite independently while Bill worked. Perhaps Bill and I were a bit crazy; after all, we had enough on our plate with a deaf-blind son and a deaf-blind mom, but love is a mysterious thing. In October 2003, Tim was born and our family was complete. Having two school-aged children and a baby on my hands was too much for me to handle alone. Bill was working and busy with culinary arts school. We realized we needed more help with the children, plus the high cost of living in the city was a struggle for us. We decided for the family's best interest, it would be better to move back to Poplar Bluff. After Joe and Ben were out of school in June, my mom flew out to Pittsburgh to escort them back to her home while Bill finished his externship for his culinary arts degree and in the late summer of 2004, we packed up our apartment, said good-bye to Pittsburgh, and drove to Missouri. The move was a good decision in many ways. Poplar Bluff, a rural town in south-eastern Missouri, has been my hometown since I was 10 years old. My extended family live there and the boys are thriving growing up among their cousins. Ben is receiving Braille and sign language services at public school and reads Braille faster than me!While both Bill and I are deeply satisfied knowing our children are happy, we have made personal sacrifices. Bill has given up his career satisfaction as a professional cook, needing to help look after the children and house. I have given up the benefits of city life such as interpreting and SSP services, not to mention the social benefits of a deaf community. But the children's well-being comes first, and I have found ways to fulfil my needs by getting involved with on-line groups for deaf-blind people, including writers and poets. I have taken a great interest in writing, especially children's stories and hope to establish a career as a writer. While I work on my computer, Bill keeps busy engaging the boys in various projects. They have built a screened-in tree house in the backyard where Ben and Tim like to sleep during warm summer nights.“It's almost 5 o'clock," Bill signed into my hand, rousing me from my thoughts. Time to prepare for our homeward journey the next day to Poplar Bluff, Missouri.Christy and Family

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [6] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm [7] Center for Disease Control and Prevention. (2021, October). Estimated HIV incidence and prevalence in the United States 2015–2019. https://www.cdc.gov/hiv/pdf/group/racialethnic/hispanic-latino/cdc-hiv-group-hispanic-latino-factsheet.pdf [8] Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [9] CDC. (2020). [10] CDC. (2020). [11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. 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