2015, 1–6, Early Online

Providing context for a medical school basic

science curriculum: The importance of the
humanities
BRITTA M. THOMPSON1, JERRY B. VANNATTA2, LAURA E. SCOBEY2, MARK FERGESON2,
HUMANITIES RESEARCH GROUP* & SHEILA M. CROW3
1
Penn State Hershey College of Medicine, USA, 2University of Oklahoma College of Medicine, USA, 3University of Oklahoma
School of Community Medicine, USA

Abstract
Introduction: To increase students’ understanding of what it means to be a physician and engage in the everyday practice of
medicine, a humanities program was implemented into the preclinical curriculum of the medical school curriculum. The purpose
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 06/12/15

of our study was to determine how medical students’ views of being a doctor evolved after participating in a required humanities
course.
Methods: Medical students completing a 16-clock hour humanities course from 10 courses were asked to respond to an open-
ended reflection question regarding changes, if any, of their views of being a doctor. The constant comparative method was used
for coding; triangulation and a variety of techniques were used to provide evidence of validity of the analysis.
Results: A majority of first- and second-year medical students (rr ¼ 70%) replied, resulting in 100 pages of text. A meta-theme of
Contextualizing the Purpose of Medicine and three subthemes: the importance of Treating Patients Rather than a Disease,
Understanding Observation Skills are Important, and Recognizing that Doctors are Fallible emerged from the data.
Conclusions: Results suggest that requiring humanities as part of the required preclinical curriculum can have a positive influence
For personal use only.

on medical students and act as a bridge to contextualize the purpose of medicine.

Introduction Practice points

During the first two years of medical school, students
 Requiring a 16-hour humanities course that included
encounter a medical school curriculum that is mostly an
visual arts, literature, and history allows medical
objective, scientific endeavor that requires learning factual
students in the preclinical curriculum of medical
knowledge of the science of medicine and technical skills
school helped to contextualize the larger purpose of
(Shapiro et al. 2009; Polianski & Fangerau 2012; Mullangi
medicine.
2014). This biomedical model of care, which focuses on the
 Humanities enhanced students’ view of doctoring by
detection and treatment of abnormal body structures and
encouraging their observation skills, recognition of
functions, has been the foundation of medical education since
treating patients rather than diseases, and understand-
the original Flexner report. However, overreliance on this
ing the fallibility of doctors.
foundation has led to key groups such as the Institute of
 Requiring students to take a humanities course does
Medicine (Cuff & Vanselow 2004) and the Liaison Committee
not adversely affect their ability to learn the requisite
for Medical Education (LCME 2014) to call for the inclusion
basic sciences during the first two years.
of biopsychosocial and humanities-related topics in medical
education.
Published literature has posited that the humanities discip-
lines of literature, history, philosophy, religion, art, law, among enhance their patient-centered skills, such as empathy and
others, are inextricably linked to the everyday practice of observation, and become well-rounded physicians (Shapiro
medicine. The everyday practice of medicine includes et al. 2006; Naghshineh et al. 2008; Schwartz et al. 2009; Lewis
empathy, healing, alleviating suffering, and caring for those 2011; Doukas et al. 2012).
who suffer (Vannatta et al. 2005). Proponents argue that the While many medical educators agree integrating humani-
study of humanities can provide opportunities for students to ties into medical education is important (Gulpinar et al. 2009),

Correspondence: Britta Thompson, Professor, Department of Medicine, Associate Dean for Learner Assessment and Program Evaluation, Penn State
College of Medicine, Office of Medical Education, H123, 500 University Drive, Hershey, PA 17033, USA. Tel: +717 531 0003, ext. 280809; Fax: +717
531 4786; E-mail: bthompson@hmc.psu.edu
*Humanities Research Group: Donald Bogan, Mary Zoe Baker, Mary Kay Gumerlock, Steve Orwig, Philip Minor, Hal Scofield, Andy
Sullivan, Ernesto Sanchez & Sara Tracy
ISSN 0142-159X print/ISSN 1466-187X online/15/000001–6 ß 2015 Informa UK Ltd. 1
DOI: 10.3109/0142159X.2015.1018878
 B. M. Thompson et al.
some may indicate that the humanities field is too subjective
and takes time away from the packed educational require-
ments and demands placed on an already crowded curricu-
lum (Dittrfich 2003; Mullangi 2013). In addition, many
medical students report their experience with humanities
courses as vague, irrelevant to their training, and a distrac-
tion from the biomedical sciences (Kumangai 2012). Perhaps
even more problematic for medical humanities courses is the
lack of empirical evidence to support or validate humanities’
positive contribution toward producing better physicians
(Ousager & Johannessen 2010; Mullangi 2013). One fre-
quently cited difficulty in measuring the impact of huma-
nities education on medical students is that most humanities
courses are offered as electives. Opponents suggest that
students who participate in humanities courses are a self-
selected group who may already possess more empathy
than students who do not elect to participate in such course
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 06/12/15
offerings (Schwartz et al. 2009; Shapiro et al. 2009).
Our own efforts to integrate the humanities into our
medical education program have taken a variety of forms
over the past 10 years. As part of our preclinical curriculum
renewal process, we implemented a required humanities
program to foster students’ understanding of what it means to
be a physician and engage in the everyday practice of
medicine. Our goal was to eliminate the peripheral role of
humanities as an elective course by incorporating humanities
For personal use only.
as a requirement early into the curriculum. The objective of
our study was to gain insight into how first- and second-year
medical students’ views of being a doctor evolved after
participating in a required eight week humanities course.
Methods
Humanities courses
Since 2010, all first- and second-year medical students at The
University of Oklahoma College of Medicine were required to
participate in two 16-clock hour Enrichment program courses
that included humanities, clinical service, and research. Within
the humanities, students choose from one of six different
courses offered in the fall or one of four different courses
offered in the spring. Clinical and non-clinical faculty were
recruited to develop these courses and serve as course
directors, based on their area of interest and expertise. The
size for each humanities course ranged from 8 to 20 students.
In addition to basic science courses and the Enrichment
program, students were also required to participate in a clinical
ethics course during their second year as well as a clinical
medicine course and a course on patients, physicians and
society.
Each of the classes met two hours a week for eight weeks.
Reading and writing assignments and other activities outside of
class were limited to no more than two hours a week. Small
group discussions, experiential learning activities, and reflect-
ive writing assignments were applied across the courses.
Educational materials included films, stories, poems, biogra-
phies, and visits to the local art museum. While the content,
objectives, delivery, and facilitators across the humanities
courses varied, the overarching goal was to provide students
2
with a connection between the humanities and the everyday
practice of medicine. The humanities courses included:
Addiction Medicine, Art of Observation, Death and Dying,
Medical Reader’s Theater, Photography and Medicine,
Spirituality and Medicine, History of Medicine, Law and
Medicine, Virtue Ethics in Medicine, and Literature in
Medicine.
Data collection
Data were collected from four semesters (Spring 2011, Fall
2011, Spring 2012 and Fall 2012) of humanities courses. At the
end of each humanities course, students were asked to
respond to the following reflection question: ‘‘How have
your views of being a doctor changed, if any, as a result of this
course?’’ as part of the course evaluation. Written responses to
the reflection question were collected from students in each
course across the study period. This reflection question was
administered anonymously by a research assistant via an
online survey tool. Students were emailed a link with
instructions regarding how to access the question; reminders
were sent at one and two weeks.
To determine if the 16-hour enrichment course had any
effect on basic science performance, we also looked at USMLE
Step 1 performance before and after the preclinical curriculum
renewal that included the 16-hour Enrichment Program.
Data analysis
The constant comparative method (Merriam 2009) was used
for coding the textual data. A team of analysts included a core
cadre of three faculty with expertise in medical education
research and medical humanities education. In addition, six
faculty involved in humanities education also participated in
data analysis as expert checkers (Merriam 2009). The analysts
first read all of the written comments, coding the comments
into units, units into categories, and categories into themes.
They engaged in a series of nine iterative sessions, each lasting
approximately two hours. Each session involved reading,
discussion, and graphic representation of the data. As
categories and themes began to emerge, the data were also
systematically searched for negative cases to test the categories
and themes.
To provide evidence of internal validity of the analysis,
triangulation was used. Multiple investigators independently
analyzed the data for emerging categories and themes and
came to consensus during group discussions (Merriam 2009).
Further validity evidence included using four semesters and
analyzing each separately and then together to ensure
consistency in analysis (Merriam 2009). To help readers
better understand the themes, short quotes are provided
throughout. These quotes are meant as representative(s) of the
textual data and are not meant to be exhaustive of any
particular theme. In addition, each quote represents either a
part of or the entire written reflection from a different student.
The University of Oklahoma Health Sciences Center IRB
approved this study. This study had no external funding
source.

Results
In total, 137 of 197 basic science students who were
administered the reflection question responded (response
rate of 70%), resulting in 100 pages of double-spaced textual
data. Using the constant comparative method, a meta-theme
and three sub-themes were identified. Across the courses and
semesters, the meta-theme was Contextualizing the Purpose of
Medicine and subthemes included the importance of Treating
Patients Rather than a Disease, Understanding Observation
Skills are Important, and Recognizing that Doctors are Fallible.
When the data were searched for negative cases, we noted that
data from one course, ‘‘Law and Medicine’’ did not fit the
themes identified.
Meta-theme
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 06/12/15
Contextualizing the purpose of medicine
The overarching theme of our data indicated the humanities
courses provided the opportunity for students to grasp the
bigger purpose of medicine. As one student wrote,
This course has changed my views of being a doctor
by broadening my sense of situations that doctors
face on an every day basis. Each week in this class
For personal use only.
we read a new situation, some that I could sympa-
thize with and some I could never see myself doing.
No matter the situation though, there was always
some vital lesson to be learned. Even if the lesson
wasn’t clear-cut, the situations we read about
brought touchy issues to the surface and forced us
to consider them . . . This class allowed us to begin
processing difficult situations and forced us to
consider how we might react. I think this will be
beneficial to my future as a physician because I’ve
already stopped and considered situations that I will
most definitely come across. Not only that, but I have
thought about the moral implications of my actions in
these situations and how my actions could poten-
tially ripple out. In addition, each story provided an
example of a doctor, some served as role models and
some served to show us how to not be.
They began to understand that medicine was not only
about learning the basic sciences in the first two years, but also
building skills in areas such as the humanities. As one student
wrote, ‘‘a doctor needs to know more about a broader range of
topics than strictly medical knowledge in order to be effect-
ive.’’ Students felt the Humanities allowed them to look
beyond the basic science content they were learning and
realize the importance of exploring other areas of the
world that are not just the hard, lab sciences . . . that
getting every single answer right all of the time is
not the ultimate goal of a physician; the ultimate
goal should be to live a full life and help others
do the same.
Context for basic science curriculum: Humanities
In addition, through the Humanities courses, students
recognized ‘‘many aspects of practicing medicine that are
not necessarily emphasized in medical school, but perhaps
should be.’’
Sub-themes
Sub-themes included the realization that, as future phys-
icians, they would be caring for patients with diseases, not
diseases of patients. They gained understanding about the
vital role of observation in the practice of medicine. Finally,
students began to recognize that they were not above
fallibility and in some cases, realized they might find
themselves as a patient rather than a physician through
their fallibility.
Treating patients rather than a disease
As part of contextualizing the big pictures of medicine,
students were able to appreciate they would be treating
patients as a whole rather than just a disease. One student
wrote that during their basic sciences curriculum, the
Humanities course
brought medicine back to being about people
instead of diseases and treatments. This course
made it clear why we practice medicine and how
we actually do it, things I had not otherwise spent
much time thinking about.
Further, Humanities helped put the personhood into
medicine. One student noted he/she came to realize
medicine was about ‘‘healing the person as a whole, instead
of prescribing a drug that will take away their symptoms’’,
and another indicated that because of the Humanities
course, they could ‘‘comfortably approach a patient as
they are: a person.’’
Understanding observation skills are important
We noted another sub-theme related to recognition of the
importance and skill related to careful observation, whether in
art-based, literature-based, or history-based humanities
courses. Through the Humanities coursework, students
realized
how to more acutely observe situations and
people . . . Studying situations with which I am
unfamiliar helped me to become a more empathetic
and effective physician and human being. My view
on being a doctor has not necessarily changed, but
rather has grown.
Others described the Humanities as combining
art and medicine by comparing the similarities and
difference in both fields. Being taught an artist’s skills
allows a person in the medical profession to gain
observational experience that allows them to see
what others might miss.
3
 B. M. Thompson et al.
Recognizing that doctors are fallible
To students, contextualizing medicine meant recognizing
doctors make mistakes and were fallible. Regardless of the
specific humanities course, students were introduced or
reminded about the fallibility of doctors. A representative
comment included ‘‘physicians face the same struggles that the
rest of the population faces and just because they are doctors
doesn’t mean that they are going to recognize that they need
help and that they will seek help.’’ They realized that
sometimes ‘‘the doctor is the patient and that patient
struggles . . . every day.’’
Negative cases
Interestingly, data from the Law and Medicine course did not
fit into the themes identified in all the other humanities
courses. When asked about how their views of being a doctor
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 06/12/15
had changed, the overarching theme of students in this course
was their resolve to continue to be ‘‘positive’’ and ‘‘unscathed’’
about their career choice despite feeling ‘‘bitter’’ or ‘‘jaded’’ by
learning about the law as it pertained to medicine. One
summed it up as
I find myself in a hyper vigilant state. Attention to
detail is critical in the health care service industry and
the importance I ascribe to this is now greater. Fear is
the wrong way to characterize my current thought
For personal use only.
process but it is not far from it. The course has filled
me with a general unease . . . Upon reflection, the
course was invariably depressing yet simultaneously
enlightening. All too often students do not know
enough to even ask a question. The Medicine and
Law course offered an introduction to legalese and
some of the broader issues confronting physicians
and patients today.
Basic science performance
Because opponents of the humanities suggest that there is
no time to implement humanities into an already crowded
curriculum, we examined USMLE Step 1 performance before
and after the preclinical curriculum renewal with the 16-
hour Enrichment Program using the results from two cohorts
before and after the program. We are pleased to report that
USMLE Step 1 performance did not decrease in the three
years after implementation of the program, and in fact
increased after the overall curriculum renewal which
included humanities.
Discussion
Our data indicated that medical students were able to
Contextualize the Purpose of Medicine after participating in a
humanities course during their basic science (first and second
year) training of medical school. Importantly, the addition of
16-hours of humanities did not seem to pose any negative
impact on students’ opportunity to learn basic science content,
as suggested by no adverse effect on USMLE Step 1 scores of
4
these students. These findings suggest that study, reflective
writing, and small group discussions in humanities can provide
a context – that of the patient as human – for the basic science
core curriculum. Students were reminded there was more to
being a doctor than just learning basic sciences. They also
reported that they were able to recognize that it was vital to
Treating Patients Rather than a Disease, Understanding
Observation Skills are Important, and Recognizing that
Doctors are Fallible through the humanities courses whether
through visual arts, literary writings, and history.
We were not surprised that students reported developing
their observation skills through the humanities courses.
Others have reported that the study of visual arts can
promote what some refer to as ‘‘slow looking’’ or ‘‘deep
seeing’’ (Perry et al. 2011; Doukas et al. 2012). Use of
humanities can improve, at least in the short-term, compre-
hensive and disciplined clinical observation skills (Perry
et al. 2011; Doukas et al. 2012).
We were encouraged that students indicated that their view
of being a physician had changed because they realized it was
vital to treat patients rather than diseases. Our students
reported being equipped, as the Institute of Medicine
implored, ‘‘with the knowledge and skills from the behavioral
and social sciences needed to recognize, understand, and
effectively respond to patients as individuals, not just their
symptoms’’ (Cuff & Vanselow 2004). This theme is similar to
other researchers who have suggested that humanities can
provide space for students to reflect on their own experiences
and emotions and consider what it means to be a doctor
(Rodenahuser et al. 2004; Lewis 2011; Mullangi 2013; Karkabi
et al. 2014). Humanities allow students to reconnect with
what it means to be human, improve empathy skills,
and move beyond storytelling to ‘‘story listening’’ (Hurwitz &
Charon 2013).
While many humanities courses have been implemented as
elective courses open to only a few students, all the students at
The University of Oklahoma College of Medicine participate in
a humanities course. In addition, we chose to implement our
requirement early in the medical school curriculum. Our
results suggest the importance of implementing humanities
courses and suggest that early in medical school is appropriate
and beneficial. We propose that the lessons students learn
from humanities courses in the first and second year of
medical school might act to habituate patient-centered atti-
tudes and skills, perhaps inoculating students against the
hidden curriculum especially prominent in the clinical cur-
riculum (Doukas et al. 2012; Polianski & Fangerau 2012).
Within the humanities, the disciplines of literature, art,
history, philosophy, religion, and law are usually mentioned.
It is interesting to note, however, that data from the Law
and Medicine course were different from the other
humanities courses that were offered. Students indicated
they remained dedicated and positive about choosing
medicine despite their newfound feelings of fear or jaded-
ness. If one of the goals of humanities is to habituate
patient-centered attitudes and skills and in inoculating
against the hidden curriculum, perhaps early in medical
school, then curriculum designers should be cognizant of
the types of courses that are offered.

The theme, Doctors are Fallible, is not typically reported in
medical humanities educational research. Given that this
theme emerged across the humanities offerings may suggest
that students come to medical school with an idealized vision
of being a doctor. More research is needed in this area. We
propose that medical humanities can provide the space for
medical students to acknowledge and discuss medical errors. It
provides the opportunity for first- and second-year medical
students to vicariously experience, before entering their
clinical training years, medical errors and issues such as
addictions and learn how others have dealt with them, both
cognitively and emotionally.
Although our results span several semesters of data, the
results were based on student reflections from one school
immediately after the students completed the course.
However, based on our data analysis techniques (using
multiple coders, multiple years of data, expert checkers, and
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 06/12/15
negative case investigation) and existing literature, we think
our results can be meaningful to any school considering
implementing humanities courses within the medical school
curriculum and those who have a humanities program. Future
studies should include a longer term follow-up regarding
outcomes of this program and potentially include additional
data collection methodology.
Conclusion
For personal use only.
Our study suggests that integrating visual art, literature, and
history-based humanities as part of the required basic
science curriculum can have a positive influence on medical
students. Through our 16-hour humanities program early in
the medical school curriculum, we have been able to
expose students to illness, suffering, and the everyday
practice of medicine. Importantly, students indicated their
view of doctoring had changed after completing the
humanities course in areas such as developing their obser-
vations skills, recognizing the importance of treating patients
(rather than just a disease), and broadening their view of
what it means to be a doctor. They also realized how fallible
they were and began to explore how to live with their
fallibilities as a developing doctor. We are pleased that these
gains did not negatively influence basic science learning, as
noted by the fact that USMLE Step 1 performance did not
decrease. These data provide evidence to refute the argu-
ment that humanities should not be added to an already
burgeoning basic science curriculum.
The data from this study suggest that the humanities can
help provide medical students in their basic science years with
a glimpse into the larger purpose of medicine. These courses
may act as a bridge during the basic sciences to help students
focus on the patient (including themselves) as a living body – a
whole – rather than an abstract concept – a disease.
Notes on contributors
BRITTA M. THOMPSON, PhD, is an Associate Dean for Learner Assessment
and Program Evaluation at Penn State Hershey College of Medicine. Her
research in medical education includes evaluating activities that promote
Context for basic science curriculum: Humanities
student reflection, assessing cultural competency, and determining efficacy
of curricular innovations such as humanities.
JERRY B. VANNATTA, MD, is the John Flack Burton Professor of
Humanities in Medicine and Professor of Internal Medicine at the
University of Oklahoma College of Medicine. He teaches at the medical
school as well as the Honor’s College on the Norman campus. Dr. Vannatta
was the Executive Dean of OU Medical School.
LAURA E. SCOBEY, BS, is the Coordinator of Evaluation at the University
of Oklahoma College of Medicine where she manages course evaluations
for the medical school curriculum.
MARK FERGESON, MD, is the CMRI Harris D. Riley, Jr., MD Endowed
Research Chair in Pediatric Education and Director for the Pediatric
Clerkship Program at the University of Oklahoma College of Medicine. He
is an Associate Professor in the Department of Pediatrics.
HUMANITIES RESEARCH GROUP is a group of dedicated faculty at the
University of Oklahoma dedicated to teaching and expanding the medical
humanities for medical students as well as undergraduate students.
SHEILA M. CROW, PhD, holds the George Kaiser Family Foundation Chair
in Medical Education and serves as the Assistant Dean for Curriculum &
Faculty Affairs at the University of Oklahoma School of Community
Medicine – Tulsa, OK. She is also an Associate Professor in the Department
of Pediatrics.
Declaration of interest: The authors have no interest to
declare.
References
Cuff PA, Vanselow NA. 2004. Institute of Medicine (US) Committee on
behavioral and social sciences in medical school curricula. Washington,
DC: National Academies Press.
Dittrfich LR. 2003. The humanities and medicine: Preface. Acad Med 78:
951–952.
Doukas DJ, McCullough LB, Wear S. 2012. Medical education in medical
ethics and humanities as the foundation for developing medical
professionalism. Acad Med 87:334–341.
Flexner A. 2010. Medical education in the United States and Canada: A
report of the Carnegie Foundation for the Advancement of Teaching.
New York: Carnegie Foundation for the Advancement of Teaching.
[Accessed 9 August 2014] Available from http://www.carnegiefounda-
tion.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf.
Gulpinar MA, Akman M, User I. 2009. A course, ‘The Human in Medicine’,
as an example of a preclinical medical humanities program: A summary
of 7 years. Med Teach 31:e469–e476.
Hurwitz B, Charon R. 2013. A narrative future for health care. The Lancet
381:1886–1887.
Karkabi K, Wald HS, Castel OC. 2014. The use of abstract paintings and
narratives to foster reflective capacity in medical educators: A multi-
national faculty development workshop. Med Humanit 40:44–48.
Kumangai AK. 2012. Acts of interpretation: A philosophical approach to
using creative arts in medical education. Acad Med 87:1138–1144.
Lewis BE. 2011. Narrative and healthcare reform. J Med Humanit 32:9–20.
Liaison Committee on Medical Education (LCME). 2014. Functions and
structure of a medical school: Standards for accreditation of medical
education programs leading to the M.D. degree. [Accessed 26 May
2014] Available from http://www.lcme.org/publications/2015-16-func-
tions-and-structure-with-appendix.pdf.
Merriam SB. 2009. Qualitative research: A guide to design and implemen-
tation. San Francisco, CA: John Wiley & Sons.
Mullangi S. 2013. The synergy of medicine and art in the curriculum.
Acad Med 88:921–923.
Mullangi S. 2014. Presenting the case for the medical humanities.
Vir Mentor 16:592–594.
Naghshineh S, Hafler JP, Miller AR, Blanco MA, Lipsitz SR, Dubroff
RP, Khoshbin S, Katz JT. 2008. Formal art observation training
5
 B. M. Thompson et al.
improves medical students’ visual diagnostic skills. J Gen Intern
Med 23:991–997.
Ousager J, Johannessen H. 2010. Humanities in undergraduate medical
education: A literature review. Acad Med 85:988–998.
Perry M, Maffulli N, Willson S, Morrissey D. 2011. The effectiveness of arts-
based interventions in medical education: A literature review. Med
Educ 45(2):141–148.
Polianski IJ, Fangerau H. 2012. Toward ‘‘harder’’ medical humanities:
Moving beyond the ‘‘two cultures’’ dichotomy. Acad Med 87:121–126.
Rodenahuser P, Strickland MA, Gambala CT. 2004. Arts-related activities
across U.S. Medical Schools: A follow-up study. Teach Learn Med
16(3):233–239.
Med Teach Downloaded from informahealthcare.com by Nyu Medical Center on 06/12/15
For personal use only.
Schwartz AW, Abramson JS, Wojnowich I, Accordino R, Ronan EJ,
Rifkin MR. 2009. Evaluating the impact of the humanities in medical
education. Mt Sinai J Med 76:372–380.
Shapiro J, Coulehan J, Wear D, Montello M. 2009. Medical humanities and
their discontents: Definitions, critiques, and implications. Acad Med 84:
192–198.
Shapiro J, Rucker L, Beck J. 2006. Training the clinical eye and mind: Using
the arts to develop medical students’ observational and pattern
recognition skills. Med Educ 40:263–268.
Vannatta J, Schleifer R, Crow S. 2005. Medicine and humanistic under-
standing: The significance of narrative in medical practices.
Philadelphia, PA: University of Pennsylvania Press.