Avoidant Restrictive Food Intake Disorder (ARFID)-Looking beyond the eating disorder lens?

Avoidant Restrictive Food Intake Disorder (ARFID) was first included as a diagnostic category in 2013, and over the past 10 years has been adopted by the international eating disorder community. While greater awareness of these difficulties has increased identification, demand and enabled advocacy for clinical services, the heterogeneous nature of ARFID poses unique challenges for eating disorder clinicians and researchers. This commentary aims to reflect on some of these challenges, focussing specifically on the risk of viewing ARFID through an eating disorder lens. This includes potential biases in the literature as most recent research has been conducted in specialist child and adolescent eating disorder clinic settings, bringing in to question the generalisability of findings to the broad spectrum of individuals affected by ARFID. We also consider whether viewing ARFID predominantly through an eating disorder lens risks us as a field being blinkered to the range of effective skills our multi-disciplinary feeding colleagues may bring. There are opportunities that may come with the eating disorder field navigating treatment pathways for ARFID, including more joined up working with multi-disciplinary colleagues, the ability to transfer skills used in ARFID treatment to individuals with eating disorder presentations, and most notably an opportunity to provide more effective treatment and service pathways for individuals with ARFID and their families. However, these opportunities will only be realised if eating disorder clinicians and researchers step out of their current silos.

Cell division angle predicts the level of tissue mechanics that tune the amount of cerebellar folding.

Modeling has led to proposals that the amount of neural tissue folding is set by the level of differential expansion between tissue layers and that the wavelength is set by the thickness of the outer layer. Here, we used inbred mouse strains with distinct amounts of cerebellar folding to investigate these predictions. We identified a distinct critical period during which the folding amount diverges between the two strains. In this period, regional changes in the level of differential expansion between the external granule layer (EGL) and underlying core correlate with the folding amount in each strain. Additionally, the thickness of the EGL varies regionally during the critical period alongside corresponding changes in wavelength. The number of SHH-expressing Purkinje cells predicts the folding amount, but the proliferation rate in the EGL is the same between the strains. However, regional changes in the cell division angle within the EGL predicts both the tangential expansion and the thickness of the EGL. Cell division angle is likely a tunable mechanism whereby both the level of differential expansion along the perimeter and the thickness of the EGL are regionally tuned to set the amount and wavelength of folding.

Development of an Actor Rehearsal Guide for Communication Skills Courses.

BACKGROUND: Established models of serious illness communication training frequently include role play with simulated patient actors. Yet preparing for communication courses can feel challenging, as most faculty have minimal experience directing actors, and no literature exists to guide faculty in how to lead course rehearsals. METHODS: A team of palliative care educators partnered with a seasoned acting teacher to design and implement a faculty guide for directing actors during communication course rehearsals. Their approach involved a series of brainstorming sessions, creation and piloting of a draft rehearsal guide and revisions based on actor and faculty feedback. RESULTS: The actor rehearsal guide offers a stepwise approach to beginning a rehearsal, rehearsing a patient case, giving feedback to the actor and ensuring the actor responds appropriately to learners of varied skill levels. From early 2021 to late 2022, the team used the guide to prepare for 36 courses, which trained 446 clinicians. Faculty and actors noted that the guide fostered predictable and efficient rehearsals. CONCLUSIONS: A novel actor rehearsal guide can support preparation for communication courses at a single institution. Next steps include disseminating the guide to other institutions and evaluating the guide's impact on faculty and actors' experience of rehearsals and learners' experience of training.

Defining Key Elements of a Clinical Experience in Hospice and Palliative Medicine for Medical Residents in the United States.

Training in hospice and palliative medicine (HPM) is essential for practicing internists, who routinely care for patients and families facing serious illness. Program directors and medical residents acknowledge the importance of palliative medicine skills, and trainees themselves desire more such training. The ACGME has also recognized the importance of HPM training for medical residents, establishing in its 2022 Common Program Requirements for Internal Medicine a new expectation that all residents have a clinical experience in HPM. However, internal medicine residencies vary significantly in their approach to teaching HPM skills, and what constitutes a useful clinical experience in HPM has not been well-described. In this perspective, we draw from the available literature and our experience as educators to propose 5 core elements for creating an optimal HPM experience for medical residents. These include practice with symptom management and communication in serious illness, exposure to interdisciplinary care, appreciation of the continuum of care settings for HPM delivery, and an understanding of the key principles of hospice care. We then describe the relevance of each element and offer educational strategies regarding how each can be achieved.

Something Lost and Something Gained: Navigating the Bedside Teaching Role as a Hospice and Palliative Medicine Educator.

Hospice and palliative medicine (HPM) educators must often give up the satisfaction of working one-on-one with patients, to allow learners the opportunity to practice key communication skills and form their own therapeutic bonds with patients. Though the loss of that primary relationship with patients may feel challenging, educators may find new opportunity for professional impact and satisfaction by investing in their relationship with learners. This case discussion explores the challenges of bedside teaching in HPM, including the educator's looser connection with patients, need to withhold their own communication skills, and decision of when to interject into a trainee-patient conversation. We then propose strategies to help educators find renewed professional fulfillment in the teacher-learner relationship. By partnering intentionally with learners before, during, and after shared visits, inviting informal reflection between encounters, and preserving independent clinical time, we believe educators may cultivate a more sustainable and meaningful clinical teaching practice.

Cell division angle regulates the tissue mechanics and tunes the amount of cerebellar folding.

Modeling has proposed that the amount of neural tissue folding is set by the level of differential-expansion between tissue layers and that the wavelength is set by the thickness of the outer layer. Here we used inbred mouse strains with distinct amounts of cerebellar folding to investigate these predictions. We identified a critical period where the folding amount diverges between the strains. In this period, regional changes in the level of differential-expansion between the external granule layer (EGL) and underlying core correlate with the folding amount in each strain. Additionally, the thickness of the EGL is regionally adjusted during the critical period alongside corresponding changes in wavelength. While the number of SHH-expressing Purkinje cells predicts the folding amount, the proliferation rate in the EGL is the same between the strains. However, regional changes in the cell division angle within the EGL predicts both the tangential-expansion and thickness of the EGL. Cell division angle is likely a tunable mechanism whereby both the level of differential-expansion and thickness of the EGL are regionally tuned to set the amount and wavelength of folding.

Topical Review: Teaching Serious News Delivery in Eye Care.

SIGNIFICANCE: Eye doctors regularly convey serious illness news to their patients. There is an evolving understanding of how medical educators can effectively teach this vital communication skill during real-time patient care. This article proposes teaching strategies to improve clinical optometric education related to serious illness conversations.Effectively conveying serious illness news is an essential skill in optometry practice. Established protocols can help optometrists navigate these nuanced, emotional, and complex conversations with patients, yet protocols for teaching this skill in eye care settings have not been described. Clinical educators need discrete strategies for making such pivotal communication skills learnable in an environment where patient care, teaching priorities, and limited resources are regularly juggled. Despite the importance of this competency, limited study has focused on teaching optometry learners to deliver serious eye news. In this article, we explore the importance of optometry talk, serious news delivery tools, and considerations for optometric educators teaching serious news delivery. We then adapt specific strategies from medical education to help optometry educators teach serious news delivery in clinical settings.

The Tween Years: Thriving as a Mid-Career Academic Hospice and Palliative Medicine Clinician.

In the young and rapidly evolving field of hospice and palliative medicine (HPM), the transition from early to mid-career can be a precarious time. The high rates of burnout and low rates of work-life balance and satisfaction found in mid-career jeopardize our field's ability to maintain a healthy workforce. In this series, we present three cases that highlight common issues encountered during the early to mid-career transition in academic HPM and present several strategies for navigating challenges. A web of mentors/connections, academic map, and continuing education to enhance teaching skills are several concrete tools explored. To sustain a robust HPM workforce, such practical and structured supports during the particularly challenging mid-career transition are crucial.

Perspectives of internal medicine residents on approaching serious illness conversations.

BACKGROUND: Navigating serious illness conversations is a critical competency for clinical trainees in any discipline, yet many feel underprepared to engage in such conversations. This study explored the challenges and emotions experienced by residents (junior doctors) when approaching serious illness conversations and how their perceptions might inform the development of effective communication skills curricula. METHODS: Using qualitative methodology, we explored the prior experience of Internal Medicine residents who attended communication skills workshops at Brigham and Women's Hospital between January and May 2020. Using an open-ended questionnaire, we solicited participants' reflections on conducting serious illness conversations. Narratives were de-identified and analysed for key themes. The Mass General Brigham Institutional Review Board approved the study. FINDINGS: Fifty-one out of 70 eligible residents (72.8%) completed the questionnaire. Qualitative analysis identified five key themes: (a) finding the time to do it right, (b) fear of using the wrong words, (c) managing the patient's response and emotion, (d) not knowing how much they can say and (e) finding meaning and fulfilment. Residents also proposed several practical strategies to enhance their communication training. DISCUSSION AND CONCLUSION: Though serious illness conversations were reported as stressful, study participants emphasised that the experiences enabled them to forge meaningful therapeutic relationships and led to a sense of fulfilment. The strategies recommended by our residents offer valuable insights to improve communication training, including through increased simulated and real-time skills practice. Cocreation of curricula by trainees and faculty could potentially address trainees' challenges, promote essential skills, and foster professional identity formation.

Palliative care in dermatology: A clinical primer, review of the literature, and needs assessment.

Palliative care has been shown to improve quality of life, symptoms, and caregiver burden for a range of life-limiting diseases. Palliative care use among patients with severe dermatologic disease remains relatively unexplored, but the limited available data suggest significant unmet care needs and low rates of palliative care use. This review summarizes current palliative care patterns in dermatology, identifying areas for improvement and future investigation.

Usage Patterns of a Web-Based Palliative Care Content Platform (PalliCOVID) During the COVID-19 Pandemic.

CONTEXT: The COVID-19 pandemic has highlighted the essential role of palliative care to support the delivery of compassionate, goal-concordant patient care. We created the Web-based application, PalliCOVID (https://pallicovid.app/), in April 2020 to provide all clinicians with convenient access to palliative care resources and support. PalliCOVID features evidence-based clinical guidelines, educational content, and institutional protocols related to palliative care for COVID-19 patients. It is a publicly available resource accessible from any mobile device or desktop computer that provides clinicians with access to palliative care guidance across a variety of care settings, including the emergency department, hospital ward, intensive care unit, and primary care practice. OBJECTIVE: The primary objective of this study was to evaluate usage patterns of PalliCOVID to understand user behavior in relation to this palliative care content platform during the period of the local peak of COVID-19 infection in Massachusetts. METHODS: We retrospectively analyzed deidentified usage data collected by Google Analytics from the first day of PalliCOVID's launch on April 7, 2020, until May 1, 2020, the time period that encompassed the local peak of the COVID-19 surge in Massachusetts. User access data were collected and summarized by using Google Analytics software that had been integrated into the PalliCOVID Web application. RESULTS: A total of 2042 users accessed PalliCOVID and viewed 4637 pages from April 7 to May 1, 2020. Users spent an average of 2 minutes and 6 seconds per session. Eighty-one percent of users were first-time visitors, while the remaining 19% were return visitors. Most users accessed PalliCOVID from the United States (87%), with a large proportion of users coming from Boston and the surrounding cities (32% of overall users). CONCLUSIONS: PalliCOVID is one example of a scalable digital health solution that can bring palliative care resources to frontline clinicians. Analysis of PalliCOVID usage patterns has the potential to inform the improvement of the platform to better meet the needs of its user base and guide future dissemination strategies. The quantitative data presented here, although informative about user behavior, should be supplemented with future qualitative research to further define the impact of this tool and extend our ability to deliver clinical care that is compassionate, rational, and well-aligned with patients' values and goals.

Development of a Palliative Care Toolkit for the COVID-19 Pandemic.

The Coronavirus disease 2019 (COVID-19) pandemic has led to high numbers of critically ill and dying patients in need of expert management of dyspnea, delirium, and serious illness communication. The rapid spread of severe acute respiratory syndrome-Coronavirus-2 creates surges of infected patients requiring hospitalization and puts palliative care programs at risk of being overwhelmed by patients, families, and clinicians seeking help. In response to this unprecedented need for palliative care, our program sought to create a collection of palliative care resources for nonpalliative care clinicians. A workgroup of interdisciplinary palliative care clinicians developed the Palliative Care Toolkit, consisting of a detailed chapter in a COVID-19 online resource, a mobile and desktop Web application, one-page guides, pocket cards, and communication skills training videos. The suite of resources provides expert and evidence-based guidance on symptom management including dyspnea, pain, and delirium, as well as on serious illness communication, including conversations about goals of care, code status, and end of life. We also created a nurse resource hotline staffed by palliative care nurse practitioners and virtual office hours staffed by a palliative care attending physician. Since its development, the Toolkit has helped us disseminate best practices to nonpalliative care clinicians delivering primary palliative care, allowing our team to focus on the highest-need consults and increasing acceptance of palliative care across hospital settings.

Exploring and Managing the Impostor Phenomenon in Palliative Care: A Case Series.

The impostor phenomenon (IP) describes the experience of questioning one's abilities and fearing exposure as an intellectual fraud, despite objective evidence of success. The IP has been identified in high-achieving professionals across a variety of disciplines, including clinical medicine, and can be associated with significant anxiety and psychological distress. In this series, we present three authentic cases that demonstrate how the IP may manifest in palliative care practice. Acknowledging the current emphasis on clinician wellness and burnout, we suggest that the IP may be one important source of distress for many early-career clinicians in palliative care. With the physician as the focus of each case, we explore the difficult emotions faced and highlight how palliative care clinicians may be uniquely vulnerable to the IP. We then identify concrete strategies to help clinicians manage feelings of IP and enhance their professional well-being.