Background -The theory of Threshold Concepts (TC) proposes that there are ideas necessary for a student to learn which enable them to think like a professional. Studies of TC in higher education have appeared since 2003. Studies in medical education are more recent.

Introduction: Progress Notes is a literary magazine featuring works from health care students in the USA. It is edited by medical students at the Uniformed Services University of the Health Sciences (USUHS) to provide a space for their creative works. Since the magazine's inception in 2016, four volumes have been published, containing 130 works of poetry, fiction, reflection, and artwork. Goal: To understand the themes and perspectives of the published works. Methods: After Institutional Review Board approval, two researchers used qualitative thematic analysis to examine the texts, coding independently and resolving differences by discussion. They arranged the codes into themes which were discussed until consensus. A third researcher read the texts, codes and themes and verified that they were an accurate reflection of the published works. Artwork was assigned themes by the same two researchers who analyzed the written works, and a sample selection was verified by the third researcher. Results: Researchers identified eight themes across poetry, fiction, and reflective essays: vocation, death, failure/resilience, emotional restraint, personhood of the patient, approach to the patient, military physicians, and moments of personal realization. Four themes were identified in the artwork: death; comradeship/aloneness; vocation/quest; and competence. Discussion: Students submitted creative works in which they grapple with what it means to be a physician. Analyzed through the lens of the threshold concepts, researchers identified: "I am a healer;" "I can deal with ambiguity;" "The patient is the focus;" "As a military medical officer, I serve two masters;" and "As a physician, I have a unique and complex relationship with death." These threshold concepts represent an ontological shift in the students' professional identity. Conclusion: A literary magazine edited, and featuring works by, health care students provides a forum in which

Introduction Operation Bushmaster, a 5-day high-fidelity medical practicum bringing together fourth-year medical students, graduate nursing students, international students, and physicians and other medical professionals in emergency and operational medicine from across the world, is the capstone event of the Uniformed Services University of the Health Sciences’s Military Unique Curriculum. It is designed to simultaneously test students’ medical knowledge, leadership skills, and grace under fire. For many students, this experience represents one of the first times that they concurrently inhabit the dual roles of military officer and (soon-to-be) physician. This is likely the most “tactical” and stressful military simulation that many students have experienced. Methods In this qualitative study, we analyzed a data set of 49 de-identified reflective articles written by fourth-year medical students following the completion of Bushmaster, in order to understand what students gained from the experience. Additionally, we evaluated students’ responses through the lens of the threshold concept, looking for ontological shifts, integration, discursiveness, and troublesomeness during students’ Bushmaster experiences. Results We identified 10 themes throughout the essays that highlighted the lessons learned during the Bushmaster experience, including its importance in guiding professional identity formation and students’ deepened understanding of the unique responsibilities and pressures of the role of military physician. Conclusion One of the resulting themes, “the military physician,” met our criteria for a threshold concept, in that it was transformative, integrative, and troublesome. Before Bushmaster, many of the students saw themselves simply as medical students rather than as almost doctors. Following the field practicum, some identified more strongly with the role of military physician, while others continued to overestimate the amount of time remaining to complete the transformation from student to doctor or to integrate the roles of physician and military officer. Moreover, we identified the entirety of Bushmaster as a threshold experience. This work serves to further describe the liminal space in which military medical students reside on their journey to physician, as well as the moment of realization by many that becoming a military physician encompasses more than simply the sum of the roles of physician and military officer.

Differences emerge between definitions of professionalism that appear to relate to training and experience. Students' views of professionalism reflect the immediate context of their educational environment. Curricula targeted to the students' foci are relevant in teaching professionalism.

Increased involvement of patients and families in full partnership with medical educators is a logical outgrowth of changes in relationships between patients and health care providers as described in medical literature.