Gender-based violence is considered a serious social and public health problem. Overcoming this situation implies a process that results in the favorable biopsychosocial rehabilitation of the resilience of women. The objective of this study was to analyze the tools, resources and personal and psychosocial mechanisms used by women survivors of gender-based violence. The design was an interpretative phenomenology. It was carried out with 22 women who have overcome gender-based violence. Data were collected through personal interviews and narration. The results were grouped into four themes: “Process of violence”, “Social resources for coping and overcoming GBV”, “Personal tools for coping and overcoming GBV” and “Feelings identified, from the abuse stage to the survival stage”. Several studies concluded that overcoming abuse is influenced by the women’s social network, and it can be the action of these people determining their survival to gender violence. Despite the recognized usefulness of these available resources, it would be desirable to strengthen them in order to be able to drive more women toward survival, assuming a strengthening of coping and overcoming, without forgetting the importance of other support mechanisms, such as their family and group therapies. Gender-based violence (GBV) is one of the most important social problems in Spain, given both the increase of abuse and a much higher number of cases in 2020 . It is dThe Macro Survey on Violence Against Women, conducted by the Spanish Ministry of Health, Social Services and Equality (2019), found that over 11% of Spanish women have suffered some type of physical aggression by a current or past partner. These were repeated aggressions in 75.2% of the cases, and single incidents in slightly over 12%. These figures are quite alarming, as they indicate that in most cases of GBV, aggressions are repeated over time. In 49% of the cases, the aggressions were by former partners, while less than 5% were committed by current partners .When addressing women’s perception regarding the consequences of GBV, the severity increases when the perpetrator is an ex-partner (46.2%), while it drops by more than half if it is the current partner (24.5%). After an attack, women most frequently feel powerless and sad .In 2019, 85,318 calls were received at the National Information and Legal Advice Hotline for women victims of GBV across the country, while 143,535 police reports were filed. In the province of Huelva, 925 calls were received, with over 60% of them coming from the women themselves, and 1,932 police reports were filed. In addition, one woman died in the province, the first since 2011 [Overcoming GBV is a biopsychosocial rehabilitation process for women and their children, during which post-traumatic growth takes place to devictimize them and separate them from any negative consequences, such as mental illness. The process includes enhancing the natural ability of human beings to resist and overcome adversities . This isThroughout the episodes of violence, the influence of the women’s social network should be taken into account, primarily the natural one made up of their family members and/or trusted friends. When these people learn about the situation, they can react with feelings of rage or anger, consequently victimizing the aggressors, or they can create conflicts between the women and these individuals, given their emotional dependence on them. Other family members may blame the victims for the violence or even feel ashamed of the situation. They may try to control them or even play down the abuse, doubting the credibility of the women’s testimony ,9,10.From an institutional perspective, the action of an organized social network, made up of government and non-government resources , which aThe objective of this study was to analyze the tools, resources and personal and psychosocial mechanisms used by women survivors of gender-based violence.This is a qualitative study using interpretative phenomenological analysis, in line with Heidegger’s principles ,13,14,15The sampling used was theoretical and purposeful ,17, withThe inclusion criteria considered were women of legal age (over 18), residents in Spain, separated from their aggressors with whom they had had no contact for 3 years or more, active in the labor market (either working and/or looking for a job) and who voluntarily decided to participate in the study.The exclusion criteria were women for whom talking about their experience of abuse caused physical and/or mental suffering and/or women living in short and/or medium stay social institutions such as shelter homes.Data were collected through semi-structured interviews carried out during personal appointments with 4 of the participants, while the rest decided to provide their data in written semi-structured reports with the same questions used in the interviews .We read the informants’ description in order to acquire and compare contents;We obtained significant statements for each description and coding;We explained the meaning in detail of each significant statement in order to formulate meanings and continue coding;We organized the complete set of statements was into groups;We compared the groups with the original comparisons in order to validate the groups and find discrepancies;We conducted an exhaustive description of the phenomenon, integrating the results from the previous steps;We consulted participants in order to validate the original data.The data analysis strategy followed Colaizzi’s approach ,20, whicThe study was subject to the four principles of bioethics. The first three were the principle of beneficence, which aimed to use the data collected in the interviews to help women who are currently victims of abuse, while respecting the participants in the study, the principle of non-maleficence, under which no woman may be intentionally harmed and the principle of autonomy, which was accepting and respecting the decisions of the women, who voluntarily participated in the study and could leave it at any time. To this end, they signed an informed consent (IC). The fourth principle was the principle of justice, which guided the study, as the intention was to discover the most appropriate mechanisms used by the women who had been through this type of situation and make them available to those who needed them ,22.All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of 1801201702017.The rigor of this study was determined by the following criteria: (a) confirmability is guaranteed by describing the women’s characteristics and by using a literal transcription of their input; (b) transferability is achieved since the results obtained can be transferred to other similar studies ,24,25.Results were grouped into four themes: “Process of violence”, “Social resources for coping and overcoming GBV”, “Personal tools for coping and overcoming GBV” and “Feelings identified, from the abuse stage to the survival stage” .The process of violence included a series of aggressions, a process of identification, an initial action by the women to stop the abuse and a series of consequences.The aggressions the women reported were physical. They were objective injuries that could trigger a reaction from family members or social workers as well as causing a mark for life that they tried to conceal, while sexual aggressions went unnoticed.-“Because of course we couldn’t have sex with a condom, right? Then it happened, aside from, well, he didn’t force me to have sex, but it was a bit like we had to do it.” (16)-“He beat me up terribly and destroyed my house.” (7)Additionally, there was psychological harm that intimidated them and made self-defense impossible. The aggressor’s constant manipulation made them feel like they had no value as a person and it socially destroyed their natural support network by distancing them from the most important people in their lives, which made them feel alone and abandoned.-“He would say that control was love, but I knew it was possession.” (13)-“He would yell at me for everything and make me feel I was worthless.” (2)-“I started to feel dirty, alone and despised.” (7)Similarly, a series of financial aggressions were identified. They were stripped of their property rights, belongings that had monetary and sentimental value were destroyed and they felt vulnerable and unable to make decisions.-“He wouldn’t give me money for the house, he would go to play bingo and when he got home he would beat me, and force me to do things I didn’t want to do.” (12)During the identification process, women refused to see themselves as victims. They did not accept the image imposed on them by society of being weak, blinded by love, of low social class and with no education, which was a hard blow for their self-esteem. Furthermore, some of them did not think that their partners were abusing them until the aggressions became physical and they became afraid, because the psychological aggressions they had experienced were not considered acts of gender violence.-“Well, let’s see. For a long time I did not want to feel like a victim. So it was like, I am going through everything that could objectively be called gender abuse, but I am not an abused woman, but rather this is something that happened to me.” (16)-“When I truly began to fear for my physical integrity I told him I wanted to leave him, I’d had enough.” (16)This process of identification would include their children’s suffering, an attempt to get out of the situation, although unsuccessfully, while maintaining a bond with the aggressor and returning to the acts of aggression that got even worse.-“He started abusing his daughters, not only me.” (8)-“The trigger was my daughters’ suffering.” (1)After all these experiences, and in an attempt to improve the situation, the women would begin to take steps, such as reporting the violence to the police, breaking up the relationship and/or leaving home and calling for help.-“To stop the abuse I reported it to the police and went to a shelter.” (5)-“I left him the moment I knew it was abuse.” (2)The results or consequences were devastating, including the onset of non-specific illnesses, sleep disorders, anxiety, nightmares, emotional stress, hypersensitivity towards social image and the inability to see the future. Some of them considered that they had not yet overcome the violence since their memory of the trauma was visible in their everyday life.-“Yes, I have physical sequelae. He gave me the human papillomavirus.” (16)-“Many physical sequelae and even more psychological ones”. (9)-“My body reacts by sweating a lot, not sleeping much, with diarrhea, vomiting and panic attacks, anxiety.” (9)-“I have nightmares about him. There is a nightmare that I had several times where I am in different situations and I see his head at a distance and I feel horribly terrified” (16)Access to resources available for coping and overcoming violence was different in each case. Some had a natural social support network made up, primarily, of family members and friends, who would provide mental and physical support that could favor their empowerment, detachment from their aggressor and make them feel protected. In other cases, the women did not have anyone nearby or people nearby offered to give them a hand.-“I received support and affection from all my loved ones.” (7)-“My family distanced themselves from the situation, they stayed away.” (6)-“My parents were the best and greatest support I had, and with my siblings I have no relationship because they say I am to blame for everything that I have gone through.” (9)On the hard path towards resilience, some decided not to talk about their experience to avoid worrying those around them, to not appear weak or ashamed and also to prevent confrontations with the people they trusted.-“I never told my family, due to shame and because I didn’t want to cause any more problems at home.” (13)Additionally, they may have come to distrust their support network because nobody believed there was abuse and defended the aggressor. Likewise, they may have felt like they were being pressured into leaving the aggressor, since the others did not understand their emotional dependence on the man or their need for some time to think things through.-“My family’s attitude was very bad, they never helped me. When I was at the first shelter he was living at my mother’s house.” (5)-“And then I had a friend who would tell me off, like: “you go back with him, you are messing up the people around you....” (16)This type of behavior by the people closest to the women were assessed as a wish for greater support or as gratitude; however, at times support was rejected since they felt that they had to overcome the violence alone.-“I would have liked help from my family, phone calls to ask how I was, showing interest in me and my children.” (5)-“I would have changed getting more support from them, not to be left alone.” (6)-“I took this as something that was mine ‘This is mine, I’m going to deal with it and I’m the one asking for help’ and I went to talk to the psychologist all by myself.” (16)With or without this natural network, they can also ask for help from organized support networks, such as the Association Miriadas, psychology professionals, therapy groups or the Andalusian Women’s Institute (IAM) and shelters. These organizations can help them feel accompanied, make their feelings of shame disappear and provide an environment where they do not feel judged and where they can receive comprehensive and personalized care.-“I learnt about Miriadas where I have been able to grow as a person and heal the consequences of the abuse. It is made up of women who were all victims of violence, and its director was also a victim. She helps us and understands us. She experienced this problem in her own flesh. She is a wonderful person and I will never forget her, she made me grow as a person and heal my wounds.” (8)-“Mutual help workshops provided by Miriadas.” (9).At times, they may feel dissatisfied with the available resources, since they demand more social assistance to facilitate their inclusion, which may not be sufficient to meet the needs of all women.-“The lack of sensibility they show us in court.” (6)-“I miss more financial resources and justice.” (1)-“There is no help for victims, and most importantly, for their children, also psychological help.” (8)-“We need assistance for a place to live, the waiting lists are very long.” (7)-“I felt helpless, without a home and with children.” (10)During the process, they improved their social skills, felt capable of accepting and facing all the adversity that they were facing and reinforced their self-esteem. All of these tools were in addition to other strategies they had been used previously, such as support and testimonials from other women victims of abuse or doing leisure activities that had been prohibited during the period of violence and that they valued more now. All of them proved they were independent from their aggressors and that made them feel free.-“We established a new circle of friends, I started mixing more.” (1)-“Now I face whatever comes, even if I lock up at first, I keep going.” (9)-“Being able to express how I feel without fear of being misunderstood, of feeling inferior.” (6)-“Once I came out of it all I realized I could manage on my own and I no longer had to depend on him as I had thought.” (4)In contrast, throughout the process, they would have feelings such as disgust for the situation of abuse and even for themselves given their insecurity and low self-esteem, guilt, shame, fear, anxiety, rage, loneliness and negation of self-worth. In general, they were ambivalent, negative or unspecific, because they felt like they did not matter to anyone and that nobody except their aggressors paid attention to them.-“He made me feel like I was worthless.” (2)-“I felt guilty, dirty, insignificant.” (9)-“The feeling I get when I remember it is sadness, sadness for having allowed it and for not having ended it all sooner.” (13)-“I feel very angry for having allowed this to happen, you know? Because I swear I realized something wasn’t right from day one.” (16)-“Yes, of course. I felt like a piece of shit because I didn’t want to break up. I felt really confused.” (16)struggle.The women described feelings of calm, relief, indifference, struggle, independence, happiness, strength and a sense of overcoming when time had passed and they had survived. Once they had overcome abuse, their memories of that period gave them a feeling of satisfaction and well-being, a feeling of pride of having made it after a long and difficult -“I am happy and I feel inner peace, and I am proud of being a survivor of this social blight.”(8)-“I felt relieved and strong enough to give myself a chance without him.” (13)-“I know I am strong and can be independent and self-sufficient, I keep telling myself this over and over again.” (13).The study conducted by Crane et al.  coincideThus, Morales et al.  cited soNeetu  identifiOgbe et al.  showed tBucuţă et al.  conducteThe study conducted by Brandt et al.  addresseThe search for participants was very difficult, since women who have suffered GBV have a hard time talking about it, and it is almost impossible to contact them directly, having to resort to the mediation of associations.Participants reported that it would have been better to include their children in the study as they consider them an inseparable part in GBV, but this consideration was not included in the objectives of the research.To study the consequences of gender-based violence and overcoming it on the descendants of the surviving women.To analyze the feelings and reflections of aggressors with regard to the abuse once their sentence has been completed, to improve the existing resources against gender-based violence and to create additional new ones.The personal tools for coping with and overcoming GBV most frequently used by the women in this study were those involving third parties: either people from their natural social network or other survivors. On the path toward resilience, many discovered other tools, such as independence or increased self-esteem.The women who had suffered GBV knew about and used the psychosocial resources available in order to overcome the traumatic experience, but pointed out the need to increase and improve them. They considered those that are provided by organized social support networks to be very useful, although some women disagreed with their actions. The natural social networks, which have an important influence on women, offered everything from strong support for the woman to no support at all, or they even sided with the aggressor. Women were grateful for the behavior of these people, but in general demanded more support.The feelings reported by the survivors of GBV were mostly negative towards themselves and the situation that they were living in, turning against the aggressor once GBV had been overcome, which is when the feelings of independence, survival, strength and a willing to fight emerged.In summary, the psychosocial resources available have been very useful for the women who wanted to get out of GBV, although reinforcing them would be very positive and would help many of them to survive, in addition to strengthening their personal coping tools, which were accompanied by both negative and positive feelings.


Introduction. This study examines differences in students’ perceived value of three artmaking modalities  and whether the resulting creative projects offer similar or different insights into medical students’ professional identity formation. Methods. Mixed-methods design using a student survey, student narrative comments and qualitative analysis of students’ original work. Results. Poetry and comics stimulated insight, but masks were more enjoyable and stress-reducing. All three art modalities expressed tension between personal and professional identities. Discussion. Regardless of type of artmaking, students express concern about encroachments of training on personal identity but hoped that personal and professional selves could be integrated. Over the past several decades, medical educators have worked diligently to integrate the arts and literature into medical school curricula  to reflect on their experiences in this first year of clinical training. The study was reviewed and approved by the UCI Institutional Review Board HS#2017-3986.Today we would like to give you an opportunity to candidly express yourself. What would you like to tell us about yourself or about your experiences in medical school? Depending on your workshop, you will either create a comic, write a poem, or make a mask as a way of reflecting.Students could choose one of the three arts options or, if they did not indicate a preference, they were randomly assigned. For the mask-making, a total of thirty-four students participated, with thirty-one choosing this activity. For the comics, twenty-eight students participated and nine chose the activity. In the poetry group, thirty-two students participated, with eight students selecting this session. The prompt for all sessions read in part: Facilitators were three individuals with expertise in teaching medical students, physicians, and other health professionals how to create comics, masks, or poetry as ways of reflecting on professional experience. Each session commenced with a brief didactic presentation explaining the art form and its uses in medical education. For the remaining time, students created masks, comics, or poetry, then shared their work in dyads, and finally participated in a large group discussion about what it was like to create original art, and what it was like to share it. Students also wrote brief narrative comments reflecting on their project.either their “work product” , the reflective narrative, or both. Researchers stated in the SIS that the work products and narratives from the session would be treated confidentially and anonymously to respect the ethical issues involved in making such personal projects  explained that they consented to participate by turning in In the Mask group, we received six reflections without masks, and twenty-eight masks with narrative reflections. In the Comics group, we received nine reflections without comics, and eight comics with reflections. In the Poetry group, we received eleven reflections without poems, and twenty-six poems (some students wrote two poems) with reflections.We conducted statistical analyses using SPSS v. 26 . We performed two ANOVA comparisons. One analysis compared all three modalities, and the second ANOVA examined the assigned/chosen data by comparing the following three groups: Verbal (assigned), Verbal (chosen), Masks (chosen) (it was impossible to include an assigned Mask group because so few students were in this category). The rationale for combining poetry and comics in the verbal groups was that both these modalities generally have a verbal, narrative concept, whereas masks focus on nonverbal, intuitive creation. Poetry and comics share an interest in cadence, rhythm and choice of word placement on a page. They both rely on a compactness and economy of words that conveys a host of meanings. Art, by contrast, is less analytical, more spontaneous, and can access tacit knowledge of which the creator is not consciously aware Kumagai .Researchers were formed into three teams, including perspectives from family medicine, psychiatry, anthropology, and psychology. Team members had prior experience analyzing either masks, poetry, or comics. To ensure consistency of approach, all team members underwent a two-hour training session to develop skills in analyzing all three modalities.Each team was assigned an equal number of masks, poems, and comics. All researchers first independently reviewed their assigned work products, producing extensive written analyses of each item. They then reviewed the narratives provided by students commenting on their own work and integrated the student perspective into their interpretations. Next, they compared these interpretations with those of their teammate.The entire research team met on three occasions for two hours each session to review the small group analyses, resolve or incorporate differences, and complete a summary grid of all findings, which was used as the basis for this paper. The team kept an extensive audit trail of all work.We applied the concept of visual rhetoric to mask analysis and to the visual part of the comics analysis  Gilligan . This apComparing the three modalities of poetry, comics, and masks, ANOVA analyses found that poetry and comics stimulated insight (self-reflection as a future doctor) for students (p=.05), while masks were more enjoyable (p =.03) and stress-reducing p<.01) for students  from the Mask group wrote:This mask represents two of the many states that I alternate between – in this case, that of spontaneity vs. premeditated. In a profession where the schedules and timelines are fixed and not flexible, I struggle to keep my spontaneity alive in the field of medicine.In a moving disclosure, one Mask student (#72) commented,The mask is a representation of how I feel at this point in my medical training. I feel pressure to speak positively of medicine and my experiences (yellow/sun colors) although I carry a lot of sadness in my head (blue/purple). My eye has been trained to see the best in situations (gold), but I have also been bruised by my experiences (black eye). I have felt anger (red cheek) and embarrassment (pink cheek) but must still speak sparkling words as I go through this journey.Researchers observed that this mask was divided into thirds, with the expressive part (the mouth) bathed in sun colors, while the mental anguish remains hidden. They speculated that the rosy cheeks were an outward sign of glowing wellbeing, but disguised feelings of anger and shame.Students who wrote poetry also struggled with what professionalism meant and what it might cost them. One student wrote in their poetry narrative, “[I’m] feeling a constant need to change who I am.” Another student-poet described their work as depicting “the struggles with conforming and becoming standardized.” Poem #43b (“Untitled”) presents professional identity as dehumanizing, threatening the personal values of the narrator. In this poem, the student witnesses the unexpected demise of a patient with a young family. The neurologist delivers the bad news briefly and dispassionately. The wife’s reaction is predictably anguished. The brief sympathy that the staff extends seems rote, designed more to protect them than to support the devastated wife. The team’s feelings are deeply buried behind literal and metaphorical masks. The student, determined to fulfill what they perceive as their professional – and human – obligation to share the wife’s pain, stays with her. In this case, the poet resists the professional role models, who appear to have betrayed their humanity and threatened values of paramount importance to the student. About this poem, the student wrote,Recounting and narrative helped me process a trauma case. Med school changes us in ways good and bad…I hope that I can retain my empathy by the end of med school.Comic #18 represents how professional training negatively impacts the student’s initial sense of readiness and self-confidence. The excitement of being in medical school and having a readiness to learn are quickly overrun by the demands of medical school on the student’s time and body. Lectures turn into moments where the student dreams, not of their future as a physician, but of rest and food. The last panel shows the student at home and comforted by food. The student noted that their comic was intended to convey “the struggles” of being in medical school. Food and rest are secondary to class but in this comic show that without those basic needs they will struggle to become the physician that they imagined.Poems, comics and especially masks often expressed the need to reconcile differing aspects of their personal and professional identities into a single authentic self that would not have to hide behind a mask. Projects from all three modalities advanced the aspiration that personal and professional identities could positively inform each other. Some projects emphasized that true professional identity should incorporate important personal values, service, good communication, and commitment to social justice.Mask #78 depicts a calm mind (a peaceful blue) with a gem symbolizing the third eye of higher consciousness and enlightenment, crowned by a wreath of twigs and bark, suggesting a connection to the natural world. In the eye sockets are reflections of others who might be patients or simply people with whom the student wants to engage. Out of the mouth a rose emerges, perhaps representing love, surrounded by green, growing tendrils. The mask implies that professional identity should include human values of dedication to others, pursuit of personal growth, attainment of wisdom, acknowledgment of others’ suffering, careful listening and right speech., for example, the writer catalogues the difficulties in their life, the sacrifices that they make, the ways they’ve changed, what they’ve endured. Nevertheless, in the final lines, this student concludes that being a doctor is still what they want, and that their relationships with patients confirm that “this is all I’ve ever wanted to be.”Poems in general were more pessimistic that reconciliation was possible, but still often expressed the aspirational hope that all their traumas eventually will make sense. Poems often expressed the feeling that their personal joy and freedom is compromised, yet cling to the possibility that they can balance the demands of the educational process with personal values and commitment to patients and thus rekindle meaning. In Poem #44Comic #21 depicts what the student experiences as a typical day, asking the question “What do you want to be when you grow up?” The second panel allows the reader to see the student walking to the hospital, stethoscope in one hand and a briefcase in the other, ready for their chosen profession. In a thought balloon, the student imagines the care that they will provide to a patient, talking with them, shaking the patient’s hand. As the student draws the events of the day, we see the phases of time passing through the window, sun rising, full sun, then stars. In each moment our student doctor is sitting in front of a computer, taking notes. During a patient visit, the student is portrayed looking at the patient file and taking notes on the computer. The student’s narrative describes their fears of what the profession might actually be like: “Working hard, being tired, and spending lots of time not interacting with people.” Yet, in the final panel, the student is still holding their stethoscope, implying their commitment to medicine remains intact.The above examples demonstrate the broad challenges to professional identity formation. The following set of themes we describe provide deeper insight into questions of identity dissonance and the hidden curriculum. These themes range from imposter syndrome to emotions related to isolation and connection.Because of their doubts about how professional identity connected with personal identity, students sometimes struggled with imposter syndrome . The dualities inherent in many masks suggested that students felt they were “pretending” to be one way – competent, knowledgeable, compassionate, and cheerful – while in fact their feelings were entirely different. For example, we see in Mask #72 that the bright, shiny portrayal is very much at variance with the student’s actual feelings. “I Don’t Know How to Help” (Poem #35a) shows a student almost paralyzed with helplessness. Seeing all sides  of the problem, the author “knows what to do, but not how to help.” Daughter is overwhelmed, patient is frustrated, and resident feels he’s done what he can do. The student sees everyone’s helplessness, including their own, but there is no meaningful path forward they can identify that addresses any of the patient’s, daughter’s, or resident’s issues. The student ends up feeling like a failure. Returning to another reading of Comic #18, the student initially feels ready to participate in an anatomy dissection, but boring lectures, hunger, and sleep deprivation dampen their self-confidence; in the end the student passes the scalpel to a classmate.Our analysis also suggested how students’ overall emotional state was related to professional identity formation. Students in the Poetry group explicitly focused on the opportunity to express their training-related emotions as a positive aspect of professional growth. As one student wrote, their goal was to “get more clarity for myself and others [about] the emotions involved in medical care.” Another student stated that they wanted to “express how tired/exhausted I am”; what resonated for them was the chance to “express my emotions.” A Comics student and a Poetry student each mentioned how important it was for them to “put the experience on paper” and “actually turn emotions into tangible words.” Another observed, “Poetry can be an expression of inner, indescribable feelings that can be therapeutic in itself and make us feel not alone.” Artmaking for these students provided clarity and connection with their emotions.Common negative emotions expressed in all three conditions were exhaustion, sadness, and loneliness, reflecting students’ struggles with professional identity formation; although the presence of positive emotions found in all three activities, such as joy, connection with others, determination, and appreciation, suggested that students still found fulfillment in their lives. Overall, masks appeared to express more positive than negative emotions and were more optimistic than the poetry and comics projects. As one student wrote about her mask project, “While there are moments of self-restriction  there is still much beauty to life that manages to flourish and grow beyond the constraints placed.” One student in the Mask group expressed their confidence in these words: “Change is inevitable but always something to grow from.” Poetry and comics projects expressed more negative than positive emotions.We often detected a longing in the creative projects for a better, happier life. Students were very aware of the sacrifices they were making to become physicians. In Mask #195, portraying a horse’s head, professional identity appears to stifle a free spirit wanting to race and roam. The student-creator wrote: “I often feel torn between my desire to become a doctor and the time commitments of medical school, and my passion for riding horses. Medical school has caused me to sacrifice a lot of my time/energy.” A haiku complained: “Why is it still dark/ When I wake up each morning?/ We all need more sleep!” By pluralizing the subject, the student makes an implicit critique of an exhausting, dehumanizing system of training. Comic #15 shows the student’s alarm going off at 4 am, the stars shining in her bedroom window. She responds to the alarm, “Kill me.”Students in all three modalities expressed the need for self-care to regain peace, relaxation, and tranquility and to recapture a sense of hope, lightness, optimism, happiness and balance that existed prior to medical school. Masks in particular emphasized the importance of fun, playfulness, creativity and spontaneity. Mask #76 portrays a divided face, with what appear to be tears dripping from one eye and a mouth filled with pebbles. Yet the mouth is in the form of a surfboard, and the other side of the face depicts a tranquil and inviting ocean, suggesting that leisure activities could offer the student a healing respite. Students in the Poetry group mentioned keeping a perspective, spiritual beliefs, and mindfulness as ways of managing stress, overcoming imposter syndrome, and serving patients. Comics often included references to the importance of healthy eating, getting enough sleep, and managing stress. Comic #112 (not shown) is a story in which medical students gather together not only to study, but to eat well, and remind each other that they should not try to tackle the challenges of medical school alone.The student narratives tended to support the quantitative results in terms of how they perceived the workshops as contributing to their personal wellness. Students experienced mask-making as a pleasant distraction or alternative to their clinical training, whereas poetry and comics were more of an opportunity to reflect on, examine, and delve deeper into often unsettling or disturbing clinical experiences. Mask-making students reported feeling “happy and relaxed,” described the experience as “cathartic,” an activity that allowed them “just to be,” and provided a “sense of release and satisfaction.” Many in the Mask group resisted the idea that their masks meant anything: "Painting is fun, don't ruin it by asking me to analyze it."Writing poetry in particular received some negative comments , although these were balanced by more positive comments . One student captured their ambivalence by commenting “Relieved it’s over (proud to have written).” Students in the Poetry group frequently commented that the process of writing helped them organize their thoughts and attain deeper insight. As one described it, what most resonated was “committing words to paper and reflecting on the imagery of my experience to think critically about how other players thought and felt.” They went on to note the “catharsis of writing.” Another commented that “writing it out is very powerful,” while a third found that “recounting and narrative helped me process trauma case.”Some of the Comics students commented that there was insufficient time to develop a narrative for the comic and also draw the story. Other students noted that they felt really stressed about drawing, but like the poetry they were glad that they were able to put their story on paper. As one student noted, “While creating the project, I felt reflective and challenged.” In observing the students after their comics drawing, many stood around in circles showing each other their comics. They laughed and commented on how good the others’ drawing or story was, then left with their comic. We are unsure if they were reluctant to share their work for the project or wanted to keep their comic to share with others.Isolation was a recurrent theme in both poems and comics that did not appear in masks. In a poignant haiku, despite three years with classmates, the student writes, “Nothing I’ve written/Could be shared with classmates/I barely know them.” In Poem #40, the student compares medical school to eating a stack of pancakes, from which one must be eaten every day, or the learner falls behind and can never catch up. The student catalogues all the family experiences they have missed because they have been faithfully “eating pancakes,” day in and day out. Ultimately, the student realizes they are sick of pancakes and especially sick of eating them alone. The poem becomes an appeal for others to join the student in helping to eat the pancakes, a yearning for a “pancake party” to break their isolation and restore a sense of enjoyment to their life.Comic #15 “Living the Dream?” is a comment on the demands of medical education and what the student says are “the lows of third year.” The comic begins with a simple 11:12 pm text to their “mom” in which they make dinner plans for what she anticipates will be a short next day. The student’s next day begins at 4 am. She is scolded by a patient soon after for being on rounds so early. Eight hours later, in surgery she is scolded for not knowing the answer to a question about an artery that she is blocked from viewing. Another eight hours and she is told that she only needs to round on twenty-seven patients. Finally, the student arrives home at 10:37 pm, feeling like a “terrible daughter.” Her mother has take-out dinner ready and tries to encourage her daughter by reminding her that this is what she had always wanted to do and that as her mother, she is “so proud.” The student replies in a thought balloon, “Not exactly.”Students perceived connection as both a need and a way of coping with some of the difficulties of medical school. We identified two types of connection – with nature and with people. A positive connection to the natural world , emerged in many of the mask projects, in contrast to no or almost no mention of nature in either comics or poetry. These masks tended to portray nature as a place of refuge from the world of medicine., the student connects with the patient’s wife and critiques the lack of connection that they see in other physicians). Masks were more evenly split, with a little over a third showing connection to other people. All the comics acknowledged connecting with others as a way of coping with the difficulties of medical school. They also revealed daily interactions and expectations that resulted in feelings of disconnection. In the Comics group, students wrote variously that “social interactions and friendships are vital in life,” “how important this person is to me” and touchingly noted that it was “quality not quantity of friendship” that mattered most.A majority of poems showed no connection with others. In these writings, there was no sense of partnership with other students or patients. The remaining poems showed either a slight or moderate connection with others , more relaxing and stress reducing (p=0.03), and would be more likely to participate in similar activities in the future (p=0.04). Because addressing this question was not part of the initial design of this study, these results are confounded by the fact that almost all the students in the Mask condition chose to participate, whereas only nine of twenty-eight in the Poetry group, and eight of thirty-two in the Comics group elected these experiences. Nevertheless, these results confirm that when students have choice, they have a more enjoyable experience. They do not answer whether they benefit more educationally than those who are assigned, as there were no differences in their self-reported personal or professional insights resulting from participation in the workshop. Future research should pursue these and related questions.tension between professional and personal identities. We interpreted this theme as related to many sub-themes, specifically imposter syndrome, isolation, a longing for wellbeing and connection, and emotional expression. These subthemes contributed to or ameliorated this overarching tension. In different ways, they both explained students’ anxieties about becoming physicians and gave them hope.Regarding the qualitative analysis, the overall theme we identified was the All three modalities were concerned with the difficulty of professional identity formation in the third year of training, and the extent to which professional identity threatened personal identity Green . OverallMany students seemed to feel that by pursuing the professional identity of a physician, they were in danger of losing their individuality and personal selves. They represented that their voices were often silenced, and they frequently felt like imposters, unable to fully conform to what they thought it meant to be a physician. Some felt coerced into a façade of cheerfulness, confidence, and certainty, whereas their subjective reality was more complex (Stephens et al. An important component of professional identity formation that emerged in all three modalities was connection or its lack. Many student projects indicated a profound sense of disconnection from others, especially in the comics and poems. Masks showed more balance. This difference may be related to a split between conscious and unconscious, with students who used the analytic, narrative form of creating poetry or comics perceiving themselves to be isolated and alone, but with mask-makers having a more intuitive, tacit awareness of connection. Nevertheless, the overall conclusion was a disturbing sense of isolation and separateness.As noted, masks showed a greater connection to nature than the other modalities, confirming an earlier study (Shapiro et al. A few other differences are worth noting. While most projects in all three modalities relied on the first person perspective, poetry experimented more with voice, which in turn may have produced greater empathy for different points of view, a finding reflected in existing literature (Chen and Forbes, One puzzle was the interpretive discrepancies between researchers and students in the mask-making condition. Some students tended not to see any deeper meaning in their work, while researchers often attributed profound insights to their projects. This was in striking contrast to comics and poetry, where interpretations of students and researchers were generally well-matched. We suspect that the differences in mask construal was because, in the absence of language, interpretation is necessarily more subjective. Also, in the absence of language, students’ unconscious issues may have surfaced without their explicit awareness.Although we used a reflexive approach to heighten awareness of our own biases, assumptions, and subjectivities, our interpretations of these arts-based projects were inevitably influenced by our past training and life experiences. Further, since all teams interpreted all modalities, we may have unconsciously been more likely to find themes we’d identified in comics, for example, reemerging in poetry and/or masks. Finally, despite efforts, we were unable to coordinate with another institution, therefore our analyses were limited to the students of a single institution.This study is one of the first to compare the effects and purposes of different arts-related modalities used in medical education. We conclude that different modalities may affect students differently. In particular, less verbally based modalities, such as visual art, may be perceived as less personally revealing and therefore more relaxing and enjoyable. Modalities that involve some level of verbal reflection and analysis, such as comics, poetry or other forms of expressive writing, may be viewed as creating more vulnerability, and therefore more stressful, but also may offer more insights.Overall, researchers found that similar themes emerged from the three arts modalities investigated. Students using all three modalities wrestled with the conflict between professional and personal identity formation; and struggled with isolation and a longing for more connection. However, an important difference was that poetry and comics tended to probe difficult clinical and educational situations, whereas masks overall conveyed more positive emotions, more perceived connectedness, and more general hopefulness.All arts are not the same. They may have differing values to learners and different purposes in their implementation. More research is needed comparing different arts modalities both in terms of how students evaluated them and what we can learn about the students who engage with them.


Drugged bodies are commonly depicted as passive, suffering and abject,which makes it hard for them to be known in other ways. Wanting to getcloser to these alternative bodies and their resourcefulness forliving, I turned to body-mapping as an inventive method for tellingdifferent kinds of drug-using stories. Drawing on a research projectwith people who inject heroin and crack cocaine in London, UK, Iemployed body-mapping as a way of studying drugged bodies in theirrelation to others, human and non-human, in the injecting event. Iinvited participants to draw their bodies in describing theseotherwise hard-to-articulate experiences. Following Donna Haraway, Iconceptualise body-mapping as a more-than-human mode of storytellingwhere different kinds of bodies can be known. Here, I look at threesuch bodies – sensing-bodies, temporal-bodies and environment-bodies –and argue that it is through being able to respond to such bodies thatmore hospitable ways of living with drugs can become possible. The drugged body…[is] a dreary parade of sucked-dry, catatonicized,vitrified, sewn-up bodies […]. Emptied bodies instead of full ones[…]. What happened? Were you cautious enough? […] Many have beendefeated in this battle.Donna Haraway: Storytelling for EarthlySurvival , likesociology more broadly , has beesymptoms, rather thananalyses’ . They continue: ‘body mapping is a way of telling stories,much like totems that contain symbols with different meanings’ (2012:5). Taken up in subsequent studies, this manual has formed aninstructive way forward for the methodology as a partial practice ofrepresentation .Rather than the drug dealer, he had forgotten their car – a constantgo-between and reminder of drugs. Reorganising what Haraway calls ‘contestedsubjects and objects of “modern progress” and “backward tradition”’ (2016:15), this kind of mapping as storytelling is able to reinvigorate how peoplelive with drugs, where drugs and other non-human others have been neglectedin favour of the drug-using subject knowable in recourseto pathology and thus make different kinds of bodies and the stories theytell matter. To quote Haraway: ‘All together the players evoke, trigger, andcall forth what – and who – exists’ (2016: 16).When social scientists find and map the capture, fixing andunfixing of the body and its machinic connections they offerhope and possibility for something different in the social.: 142body else , sensing andaffective bodies tell stories of joint learning, holding together,maintenance and care. Therefore, much like Stewart’s rejection of‘totalized systems’ in everyday America, mapping sensing-bodies inthis way brings drug-using bodies ‘into view as a scene of immanentforce, rather than leaving them looking like dead effects imposed onan innocent world’ (2007: 1).it’s what I do […] It’s a funny, it’sa very strange relationship, you do almost feel, there isa quality where it’s almost like a friend, you know, thatit’s quite comforting sometimes, the feeling is verycomforting. (emphasis added)I see it as a habit, there is a lot about getting up, gettingto the time that they [drug dealers] switch on, going outand getting the stuff and coming back and having a…youknow, having a use, that’s, a lot of that is habit, justcos Simon explains that a lot of his drug use is out ofhabit. It is what he does. This stresses the druggedbody as something we do as it goes along puts it:es along . There ies along : 186. Haes along . TherefoThe gouching part is only if you are sitting there and you’rerelaxed. If you’re up doing something, it’s not like itwill make you sit there and gouch, it doesn’t do it likethat, it depends like what you’re doing.Gwen’s body-map  depicts on the body, mappeddrugged bodies tell a different story. Far from drugs simply causingintoxicating effects, the effects are contingent. Body-mapping makesus pay attention to the non-human objects and things that so often getignored – the chair, crack house. In another example, asaforementioned, Reggie, in realising he’d left something out,exclaims: ‘aha, I’ve missed the car’. Rather than the individual drugdealer, who comes and goes, he had missed the car – an ever-presentobject in his local area that affectively triggers a desire to consumedrugs. Mapping bodies, objects and knowledges together produces aflatter scale in which objects do not simply come to stand in for moremeaningful subjects or represent bigger scenarios but can be takenseriously in their own right, intimately involved in the doing of thedrugged body.Contrary to addiction narratives of compulsion and the overpoweringpharmacology of drugs acting nothing to do, and people aren’treally going to take up menial jobs or I don’t know. It’sa vicious cycle. emphasis addedI think if you stop, when you wake up in the morning, it’llbe the first thought, but about two or three weeks downthe line, you wake up some mornings and you won’t thinkabout it, you know, you’ll think about something else. Alot of time needs to pass for you to stop, and I thinkthat’s the worst part because in the meantime, you’ve gotreally There is the potential for something different.Nevertheless, this is no easy task and Nadiya cautions: ‘a lot of timeneeds to pass for you to stop’. However, crucially, for this tohappen, she needs something else to do to pass thetime. Time is not an abstract phenomenon (an objective measure) butreliant on what we do and the ‘things’ used to navigate its passing. By seeing bodies in these temporal terms, they arealways changing, but this relies on more than the ‘doing’ of theperson who uses drugs, such as the availability of interesting jobs, to bring about the time needed to change.These drugged routines and rhythms change capacities to affect and beaffected and thus precede individuation. However, there is a paradox,just as movement seems to get locked into bodies, new movement iscreated. As rhythms get made and become imprinted they become unmade –there is always difference in repetition. Or, as Deleuze famouslysays, ‘difference inhabits repetition’ (1994: 76). This is aninherently more optimist approach than addiction, which gets drawnattention to in Nadiya’s account.with these things otherwise seen as merebackground. Another participant also highlighted the importance of thesun in whether he was able to ‘cope’ with withdrawing from heroin ornot, highlighting the extent to which these somatic ‘inner’ feelingsare heavily contingent on the ‘outside’. It is through thisback-and-forth between bodies and environments that we get to knowdrugged bodies, in this example, as attentive and at-peace (if onlytemporarily).As already seen through the body-maps earlier, bodies are made and movedin relation to others. As such, the body-maps highlight how ‘bodies’cannot be separated from their environment. Environments become anintegral part of the drugged body , and the2This fluxing ability to feel-in-the-world is similar to Simon’s accountof feeling too close to the world, which is a theme that getsrepeated. Like Vicki’s golden arch curving around the picture ofherself on the right hand side of and then a text [from a dealer] has come along […] And itwill go from me being that way [smiling face] to me beingsad [reverses the smile on the face], cos then I’ll startthinking about “scoring”.The mobile phone is a crucial part of this newconnection. Indeed, it goes off in the interview with dealers’‘adverts’ and panic-inducing messages. This then prompts Lucy to writethe word ‘drought’ in bold, which as a memory is never too far away,especially when dealers’ messages say things like ‘running low’. Ayear ago, Lucy recounts, due to the destruction of the opium poppyfields, ‘the dealers got so much control cos no one could get hold ofanything’. Mapping in this way, international drug policies becomeembodied as a loss of control, shaping response-abilities, where‘things and living beings can be inside and outside human andnon-human bodies, at different scales of time and space’  is very much part of the event to make a veinviable for injecting. And then jumping back in time and across space,to before the injecting event, as her body remembers and jerks into action:d space’ : 16.Imagining the threads of a string figure hanging off the body parts,objects and things drawn, body-environments tell stories ofconnectivity. Far from the body interacting only with the drug, thereis a whole host of things involved in thinking and living with drugs.Representation in this sense is working as more than representation.Stories do not only give accounts but refigure previously figured outand fixed bodies. Bodies are no longer submissive, environmentspassive and drugs all powerful, but they work together in producingthe drugged body that is always on the go and subject to change.Weaving together body parts, ‘natural’ surroundings, dealers, mobilephones, adverts and political interferences, mapping tells a complexstory of want and desire that disrupts and complicates the usualstories of compulsion or volition.drawing boundaries beyond the human/non-human,space/time, outside/inside, new kinds of bodies can be known and madeknowable, including what I have called sensing-bodies, temporal-bodies andbody-environments. Body-mapping thereby opens up these new ways of doingbodies with drugs. As such, this article has argued that body-maps arebetter analysed as a mode of more-than-representational storytelling, andthus, neither can they nor do they seek to capture what they attempt todepict. In this move, they call into question their own involvement in whatgets made in research. Body-mapping brings human bodies, non-human objects,substances, technologies, political interventions and knowledges into newkinds of relationships. Here, we have seen how these collective bodies, forexample, hold together and care for the body-in-flux, potentialising changeas they repeat and implicate and depend on that which is usually considered‘outside’ them in initiating drugged desires and effects. In this concludingsection, I discuss the capacity of body-mapping for invention in terms ofits experimental and speculative potential for bodies to become-with drugsdifferently.The embodied stories told here matter in that they allow other bodies tomatter. ReWhy tell stories like my pigeon tales, when there are only more andmore openings and no bottom lines? Because there are quitedefinite response-abilities that are strengthened in suchstories. (2016: 115)There are two key points here, openness and response-ability.Therefore, to detour only momentarily, I want to briefly engage with To return to As experimental devices, body-maps open up ways of not only knowing new kindsof bodies but also making them matter through a heightened response-ability.In an extension of the experiment in the natural sciences, Science andTechnology Studies scholars have started to use the term to account for theontological work that their research also does in testing and making thingsknown . But ratFurthermore, in recognising the role of researchers and methods inco-constituting the world we once merely studied, we can experiment orspeculate to create better worlds. Drawing on Haraway, among others, MariaEach time I trace a tangle and add a few threads that at firstseemed whimsical but turned out to be essential to the fabric, Iget a bit straighter that staying with the trouble of complexworlding is the name of the game of living and dying welltogether on terra, in Our ability to attune to bodies through body-mapsmatters and sensitises researchers and audiences tothese other bodies at play, thus involving them too, by which it exposes‘possible futures that cannot be managed in advance’ (with contingency. For example, policies that takeseriously the role of drugs in holding sensory-bodies together may be ableto offer substitute medication to avoid the kind of sensory overload andextreme discomfort that Simon depicts. Interventions that take seriously thecontingency of time in what the body can do will recognise – at an embodiedontological level – the necessity, as Nadiya describes, of meaningfulactivities for bodies to learn new habits. And perhaps most obviously andacutely, an appreciation for the ways bodies are entangled within druggednetworks could substantiate a more tolerant and empathetic approach to druguse based on difference.Challenging the addict body as dumb and, namely, devoid of or only tangentiallyengaging with the sensory, time-space and the environment, mapping bodiesthrough an embodied act of prompting and descriptive retelling enables newbodies to be known. For Haraway:advance’ : 7. ThisWhile mapping bodies through drawing in the interview engages those sensing-,temporal- and environment-bodies seen here, new ways of mapping bodies, suchas through art workshops, could bring about yet different kinds of bodiesand response-ability. As bodies are capacitated and incapacitated inrelation to others, including researchers and publics, it is my hope tocontinue to engage speculatively with these experimental practices instriving to bring into being new ways of living with drugs, to use Puig dela Bellacasa’s phrase, ‘as well as possible’.


The controversy in the relationship between item memory and source memory is a focus of episodic memory. Some studies show the trade-off between item memory and source memory, some show the consistency between them, and others show the independence between them. This review attempts to point out the connection-strength model, implying the different types and strengths of the important role of the item–source connections in the relationship between item memory and source memory, which is based on the same essence in the unified framework. The logic of the model is that when item memory and source memory share the same or relevant connection between item and source, they positively connect, or they are independently or negatively connected. This review integrates empirical evidence from the domains of cognition, cognitive neuroscience, and mathematical modeling to validate our hypothesis. Effective retrieval cues play an important role in memory recovery. The effect of these cues is reflected in many research studies on memory: (1) directed forgetting paradigm ; (2) mooEpisodic memory and semantic memory are two different memory systems that were proposed by Tulving to cover human memory. Tulving believed that the differences between episodic and semantic memory are self-involvement, autonoetic awareness, and subjective sense of time . Such feItem memory usually explains a lot of phenomena including false memory , workingHowever, there was a lack of a unified theoretical framework to explain the different relationships between item memory and source memory. We suggest that item memory and source memory share the same essence connections.The connection-strength model emphasizes the important role of connections between item (semantic feature) and sources in the processes of encoding and retrieval of memory, and the relationship between the item and source memory, including positive, negative, or independent relationships.Hence, we will form and introduce the connection-strength model to explain the relationships between item and source memory in the integrated framework, which is deeply based on item–source connections.In the study of memory, there are many different forms of memory. From the view of time, the memory includes “working memory,” “short-term memory,” and “long-term memory” and from the view of retrieval, the memory includes “item memory,” “source memory,” “context memory,” and “associative memory.” For However, further reflection shows that these memories share different connections: “working memory,” “short-term memory,” and “long-term memory” depend on different item-temporal connections; “item memory,” “source memory,” and “associative memory” depend on similar or different item–sources connections, which will be elucidated in the following sections. “Declarative memory” and “non-declarative memory” are retrieved relatively intentionally or automatically based on connection, respectively.From the view of Consequently, memories are merely the associative network, and “episodic memory,” “semantic memory,” “source memory,” “associative memory,” and “context memory” are the subdivisions of such network. Different concepts underlie different endpoints in the connections. Source memory emphasizes retrieving source features, item memory emphasizes the retrieval of semantic features, and associative memory emphasizes the connection between different semantic features. Even emotions can be included in this network: mood-dependent memory . The vieHowever, there is an extensive concept or term confusion among these manifestations, such as “item” and “source”: sometimes, researchers equate “item” to “semantic meaning”; sometimes, “item” means the episodic concept, the association. Therefore, in the remaining part of the manuscript, we will use the connection: “item”-“source,” in which “item” means semantic features, and “source” means other information associated with “semantic.” However, in memory systems, “item” in “item memory” means the connection. We use these depictions because most researchers utilize these terms in such a manner. In this logic, all kinds of memory can be divided into two types based on our attention focus. The relationship is shown in From the perspective of the experiences of individuals, item memory and source memory are two parts of episodic memory, which are about the semantic and its association with subjective experiences, including when, where, and how an event happened. Source memories are results of questions that ask us to explicitly point out when, where, and how an event happened. The differences between item memory and source memory are as follows: the former tries to retrieve the item based on one kind or different kinds of sources, and the latter tries to retrieve one kind of source from the item. Hence, source memory and item memory are phenomena of connections.From the perspective of the interaction between item memory and source memory, first, the memory of sources contributes to item memory; second, item memory also influences source memory. A wrong starting cue from the connection would impair true memory. This explains why the “feature-conjunction paradigm,” which shares features with presented items, would facilitate a false memory .Recognition shows the forms of “recollection,” which is associated with the experience of vivid source attributes and “familiarity” without clear source memory . Starns These examples reflect only a part of the scientific scenes we want to delineate. In various studies, there are always different relationships between item memory and source memory: (1) positive; (2) negative; and (3) irrelevant. However, there is a lack of integrated theories to explain such a controversy. We suggested that the different types and different strengths of connections between item and source, item and item, and source and source  play an important role in the relationship between item and source memory. In the next section, we presented the premises of the strength-connection model followed by the introduction of the connection-strength model. In the section “Evidence From Cognition, Cognitive Neuroscience, and Mathematical Models,” we collected evidence from domains of cognition, cognitive neuroscience, and mathematical cognitive psychology to validate our “strength-connection model” in interpreting the relationship between item and source memory.Different kinds of “connections” exist in a memory system, which is the reason for different relationships between item memory and source memory. Factors that affect the formation and extraction of “connections” are as follows: different sources of natural existence, single source or combined source, formation of connections, and extraction of connections.There are always different source features that can be divided into different types. From the viewpoint of modality , there aFrom a spatial perspective, Other kinds of sources differ in the information process or extraction process: automatic or intentional encoding, automatic or deliberate retrieval, such as the temporal compared with the neutral environment, the semantic compared with the context. Based on our attention allocation, the process is automatic or strenuous. Divided attention deeply influences the deliberative process compared with the automatic process, either in encoding or retrieval.Therefore, numerous connections are formed between and among “items” and “different sources.” These connections would also influence item memory  and Formula (3).The model originates from three existing popular theories: “spreading-activation theory” , “searchThe spreading-activation theory  emphasizThe hybrid source monitoring model  attemptsIn encoding, connections are formed in working memory and come from the shared time in the capacity of working memory. Working memory cannot simultaneously maintain excessive information. Consequently, only the item and source share the same period in working memory, and connections can be formed.Therefore, an inappropriate retrieval cue presentation impairs the free recall of a list. For example, when asking subjects to recall a list by a cued item, the recall performance would be worse than the condition of free recall with no cue . The modHowever, there are limitations in the model: (1) only other items in the list have been considered in whole connections; (2) concepts are ambiguous: “other items” is part of “context,” and the real context–temporal, semantic, and cognitive operations are not mentioned in the model; (3) such model is focused on the retrieval of item memory, not on source memory.Three theories emphasize that information connection exists in our memory systems. In addition, effective retrieval cues are very important in memory recovery. However, these models cannot explain why there are differences between item and source memory, and why there are different relationships between the two memories.The item always connects with different kinds of information, including semantic information, perceptual infor- mation, contextual information , affective information, and operative track. This information can be integrated into one cluster or one bundle, which we call “object.” The “object” involves a series of information that contributes to a whole representation. Although most of the time such integration cannot be realized by our consciousness, As a result, many connections are constructed with a difference in strengths. Among these connections, only parts of them are to be used in item memory and source memory. An effective connection is a connection with higher strength. The main differences between item memory and source memory can be seen in the connections they call. The relatively significant difference is that connections in item memory are sometimes combinations of item-sources connections. The memory retrieval probabilities for items and sources are presented in Equations (2) and (3). However, connection for source memory is a specific connection, or may be mediated by other items.SIi means the employed source-item strength in source memory decision making, and PR(sourcei) means the probability of a specific source retrieval.A rough description of the model is shown in Item retrieval follows these principles: (1) performance of item retrieval depends on the connection between item and source; (2) there are two kinds of connection: item-one-source connection and item-sources connection; (3) the higher the connection strength, the more likely it is to be called; (4) the connection strength comes from encoding period; (5) appraisal and attention are very important in the formation of connection-strength; (6) in item-sources connection, our different goal would assign a different weight to a different connection in a different experimental design. The structure is shown in Source retrieval follows these principles: (1) source retrieval depends on the ratio of a specific connection to the sum of all associated connections; (2) there are three types of connection: item-specific source connection, other item-the specific source connection, and other source-the specific source connection; (3) all the connections come from two stages: formation in the experiment and formation out of the experiment; (4) appraisal and attention are very important for the formation of connection-strength; (5) effective cues with higher strength are important for the performance of retrieval. The higher the connection strength, the more likely it is to be called. The structure is shown in The essence of item memory and source memory is the same, which depends on the connection between item and source(s) and the ratio of the called connection(s) to the sum of all associated connections. The main difference is that focus shifts from item to source, and vice versa.The relationship between item memory retrieval and source memory retrieval is: when the connection required by source memory and item memory is the same, there is a positive correlation between them; when item memory and source memory depend on different connections, for example, item memory depends on item-temporal connection, while source memory depends on item-color connection, item memory and source memory are independent of each other; when the connection required by item memory affects the formation of source memory connection, there is a negative correlation between item memory and source memory. These can be identified in the probability equation in equations (2) and (3): when the numerator of the ratio increases at the same time, the positive relationship appears, otherwise, the negative relationship will appear. When the numerator is irrelevant to each other, they are independent.There is a lot of evidence to support our model: first, the performance of source memory is always worse than that of item memory, because the connection required by the source is a part of the connections required by item memory, such as affective state as the source; second, several source memories are better than others because they call stronger connections, such as object-based colors, compared with other associated objects; third, attention plays an important role in connection formation, the more attention paid to the connection, the higher the strength of the connection; fourth, experimental design affects which connection will be encoded and called by item memory and source memory; fifth, mathematical models show that both item memory and source memory are continuous processes, which indicates that the different connection-strength deeply affects the performance of item memory and source memory. A mathematical model also shows that the confidence of item memory and source memory influences each other .The empirical evidence supporting these phenomena is as follows.The two types of experimental designs are considerably different. First, studies presenting recognition and source judgments for the same item in immediate succession have revealed chance-level accuracy in source memory with no recognition. Second, studies presenting a block of recognition followed by a block of source judgments have revealed above-chance accuracy in source memory with no recognition  that are beyond the item. Attention to “source” transfers the “source” to “item” and facilitates connections for the “new item.” The new connections increase the denominator of the probability formula, thus reducing the ratio of the item to the extrinsic source. Therefore, there is a negative relationship between item memory and source memory. Such phenomena are more deeply reflected in the memory related to emotion.Source memory can be divided into two types: intrinsic source memory, which is the features of the item itself, and extrinsic source memory, which is the associated features outside the item, including the context and objects that are associated with the item. Numerous studies support two opposite phenomena: compared with neutral items, emotional items always facilitate intrinsic source memory; however, emotional items always interfere with extrinsic source memory.The trade-off between emotional items and emotional source memory validates our theory. The first evidence comes from the relative importance of the item. Compared with positive emotional stimuli, the extrinsic source memory of negative emotional stimuli is worse . CompareThe formation of the item–source strength depends on three periods, “perception,” “evaluation,” and “association,” which can be reflected in the function of the brain: the parietal cortex, prefrontal cortex, and hippocampus. The hippocampus is the core structure in Tulving’s episodic memory. Its main function is to connect different types of information. At the same time, it is affected by different brain regions, such as the parietal cortex, frontal cortex, and amygdala. The relationship is shown in Only when a stimulus is perceived can a connection be formed. The posterior parietal cortex plays an important role in perception, such as speech, visual motion , and tacThe parietal cortex is always a bridge between perception, action, and cognition , which iExtensive research has shown that cathodal stimulation on the left posterior parietal cortex decreases the retrieval performance in source memory  and the Classic research  illustraThe prefrontal cortex has two main functions: “appraisal” and “attention allocation.” The appraisal is reflected in the situation, which reflects the evaluation of importance among different kinds of information. Researchers call this effect the “appraisal-by-content model” . The modThis effect is reflected in the processing of emotional stimuli. In the study, “A cognitive-motivational analysis of anxiety”  “appraisIncreasing research supports the function of appraisal in the prefrontal cortex. The prefrontal cortex plays an important role in the formation of connections. Research has found that normal aging and prefrontal cortex lesions are associated with poor performance in item memory and source memory . The actThe hippocampus is significant in connecting items and their sources. Other studies have shown that the activation of the amygdala due to emotional stimuli processing impairs the connection between emotion items and source features by disrupting the function of the hippocampus .The prefrontal hippocampus circuit is significant in associative memory. Different units are activated by different item presentations in the prefrontal cortex and hippocampus according to time for monkeys. The research demonstrates that both the prefrontal cortex and the hippocampus contribute to feature binding according to the timeline . InteracPrefrontal-parietal connections are also particularly important. Amygdala’s activation decreases or enhances the function of hippocampus  and inte, the results would show that the activation of different areas in the brain supports episodic or source memory.Several mathematical models attempt to explain the relationship between item memory and source memory. To answer this question, two important questions must be clarified. First, how is the experiment designed? Second, what processes are included in item memory or source memory? The different experiment designs and “processes” will influence the relationship between the item and source memory, which is based on the same or different connections in the model that we propose.These models include the “multinomial processing tree,” “receiver operating characteristic analysis,” “context maintenance and retrieval model,” and “bivariate signal detection model.” However, a detailed description of the mathematical theory is beyond the scope of this article. We merely concentrate on how the mathematical models influence our knowledge of understanding the “connection-strength” model and validate our theories.Contrary to the abovementioned evidence, mathematical models focus on retrieval processing in item and source memory. The essence that is for both encoding and retrieval is “item–source connection,” where encoding is trying to form the connection and retrieval is trying to recover the “connection” with a cue or cues. The following shows the understanding of the relationship by deploying the connection in our retrieval.The multinomial processing tree model also supports different types of item–source connections with different strengths. Not all sources can be included in an item-source network . Source Receiver operating characteristic curves are used as indices of whether the memory processes are based on the threshold criteria. The basic procedures behind the ROC are the first subjects to decide on the memory and then tell their confidence.This topic focuses on three themes: whether two kinds of memory, “recollection” and “familiarity,” share the same process; whether the item memory and source memory share the same process; and how item memory and source memory influence each other.Some studies state that “recollection” and “familiarity” share different processes: “recollection” is a threshold process, and “familiarity” is a graded process. An excellent model, which is computational and based on neurobiology, was deployed by For the question of whether the retrieval of item memory and source memory shares the same process, researchers answer this question. The “bivariate signal detection model” is an effective mathematical model for identifying the connection-strength model, which underlines existing different item–source connections. The “bivariate signal detection model,” as the special case of “multidimensional signal detection theory,” is the extension of the signal detection theory. The model considers that the mental state is large and noisy, and every action needs a judgment, and judgments can be modeled as a random sample from a multivariate probability distribution that reflects individual perceptual space. Decision-making always depends on the different axis mapping from the space in distribution.According to Johnson, memory can be divided into two types: information in the focus of our attention and information out of the focus of our attention. This dichotomy integrates a memory system into a new perspective, dividing it into item memory and source memory.Different item memory and source memory depend on the same or different item–source connections. As a result, the relationship between item and source memory is positive, negative, or irrelevant.Different item-source calls depend on the strength of the item-source(s) connection, which means that when the connection between item and source is stronger, the probability of retrieval of item memory or source memory is greater. However, when goals are proposed, different weights are added to different item-source connections; the memory then changes.In different environments, there are different goals that affect the choice of connections. This explains why item memory and source memory are either consistent or inconsistent.Cognitive processes and brain mechanisms affect the formation and intensity of connections. From the perspective of the cognitive process, attention allocation and the appraisal of the importance of items and sources would influence the formation of the item–source connection. From the perspective of brain mechanisms, the prefrontal cortex, parietal cortex, and hippocampus are associated with perception, appraisal, and connection formation, respectively. From the perspective of experimental design, the single source memory decision-making after item-random presents or block-items present determines the relationship between the item and source memory. The mathematical models support the hypothesis of the connection-strength model.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.JG was responsible for the title selection, literature collection, and writing. XH proposed the suggestions for title selection and manuscript writing. KS provided input and feedback and helped with writing. All authors contributed to the article and approved the submitted version.The content is solely the responsibility of the authors and does not necessarily represent the official views of NSFC.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


European Journal of General Practice (EJGP) editors evaluated the EJGP’s last year’s volume. In 2020, we published 36 articles, including 19 reports of original research, one systematic review, and four editorials. We had our share of COVID publications, including a background paper by WONCA Europe and several Letters to the Editor, following our first Editorial on this topic. We published three articles in the ongoing Series on eHealth. Authors came from various countries, including Belgium, Denmark, France, Greece, Hungary, Ireland, the Netherlands, Spain, and Turkey; there were a few international collaborative contributions [Like previous years, the ‘Improving the quality of antibiotic prescribing through an educational intervention delivered through the out-of-hours general practice service in Ireland’ by Nuala O’Connor et al. In their paper, the authors describe how they improved the quality of antibiotics prescription during out-of-hours services in two Irish areas. They used a simple educational information tool targeted at GPs differentiating antibiotics into ‘red’ (to be avoided) and ‘green’ . At the end of each consultation, an electronic pop-up message was displayed in the patient management software if a decision to describe an antibiotic was made. The simple intervention reduced the proportion of prescribed ‘red’ antibiotics from 44% to 17% and increased the ‘green’ antibiotic prescriptions from 56% to 83%. We encourage the publication of sound studies that are innovative and relevant, like this one. This quality improvement study could easily be replicated in other settings, areas and countries, with a clear impact on public health. Congratulations to the whole team [The Editors each selected five articles they found most valuable and of which they established the scientific quality as ‘good’. We considered relevance for family medicine , originality, methodology and possible impact on practice or research. Overall, the highest-ranking paper was ole team !Anne E. MacFarlane’s opinion paper ‘Optimising individual and community involvement in health decision-making in general practice consultations and primary care settings: A way forward’ for her apparent attempt to discuss ‘three overlapping forms of patient involvement: shared decision-making in clinical care, community participation to develop services and Public and Patient Involvement in research’ [In addition, we want to mention esearch’ .‘Lessons on the COVID-19 pandemic, for and by primary care professionals worldwide’ by Salman Rawaf et al., which we consider the most valuable contribution on COVID-19 published in this Journal in 2020. The authors stress ‘the importance of maintaining access to primary care and ongoing management of all health problems that impact the local population’. They also provide an essential lesson on communication: ‘Users of information  all have their own information needs that cannot be served by the same measures’ [Furthermore, we want to highlight the article easures’ .European Journal of General Practice.You can read these and other published articles in the European Journal of General Practice accepts around 15% of all submitted manuscripts.Finally, we want to express our gratitude to all reviewers who have advised us during the year 2020. We thank you for your appreciated assistance! Your review reports were very valuable feedback to the authors and helped us to make our editorial decisions. Currently, the http://mc.manuscript-central.com/ejgp to modify your profile. In addition, we invite all readers of the European Journal of General Practice interested in reviewing manuscripts for this Journal, to visit http://mc.manuscriptcentral.com/ejgp and to register as ‘new user’, i.e. to complete the details of their expertise.Although our database of authors and reviewers steadily increases, the Editors find it challenging to select referees within the Journal’s deadlines. Therefore, we sincerely hope that all reviewers want to continue their review work. If you would like to update your reviewer account, e.g. to specify your expertise, please visit


Introduction, Paragraph 1, 3, and 4; Results, Perceptual-Cognitive Tasks and Neuroimaging Technologies, Paragraph 2; Results, Efficiency Paradox, Paragraph 2 and should read:In the original article Vickers and Williams  was not “As increasing levels of expertise are attained, there are measurable changes in neural activation” , “thereby allowing the measurement of neural activation as specific sport tasks are performed successfully or unsuccessfully” , compared to using fMRI (11 studies) or fNIRS (one study). First, “studies can be carried out in the live ‘…Mann et al.  identifiThe authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.