A qualitative analysis of the usefulness, risks, and challenges of incorporating functionality and body compassion into the prevention and treatment of eating disorders.

Functionality appreciation and body compassion are empirically supported concepts that can help one to view their body in different and compassionate ways. However, they have yet to be applied to eating disorder (ED) samples and therefore it is important to explore the perceived benefit, risk, and nuance in this population. Semi-structured interviews (N = 25) were conducted with treatment providers, those with a lived experience of an ED, or history of body image distress. Usefulness, applicability, potential risks, benefits, and desired delivery format were probed. Thematic analysis was used. Participants reported that compassion and functionality approaches were useful, complement existing treatment approaches, and important for early intervention. Although considered safe, caveats were noted for ED samples, including introducing content at the right time (e.g., when medically stable), and when having the cognitive flexibility to think about one's body in different ways. For example, functionality appreciation could trigger thoughts about what one's body cannot do while compassion may allow for normalising negative thoughts. Both concepts were viewed as useful and safe to support positive body image at a community level and can be used with ED samples with additional support. This insight from potential users helps with co-design of appropriate content.

The imperative of collaboration: Lived experience perspectives on team approaches in outpatient eating disorder treatment.

BACKGROUND: Across healthcare broadly, team treatment approaches range from siloed multidisciplinary treatment to synergistic Interprofessional Collaborative Practice (IPCP), with IPCP increasingly favored. In eating disorders, clinical practice guidelines endorse team outpatient treatment, and these approaches are widely used in clinical practice. However, there is limited evidence to describe attitudes toward and experiences of team approaches, including IPCP, among individuals with a lived experience. METHOD: Twenty-seven participants (aged 20-51 years) with a formal eating disorder diagnosis were recruited. Each had received outpatient eating disorder treatment from a team or teams comprising a mental health professional, dietitian, and general practitioner (GP) in the past 2 years. Qualitative data were collected via semi-structured interviews and analyzed using Braun and Clarke's reflexive thematic analysis. RESULTS: Four themes were derived from the qualitative analysis. Themes included: (1) working together is better; (2) the linchpin of teamwork is communication; (3) teams should foster autonomy with limit-setting; and (4) systemic failures negatively affect team treatment. Participants favored highly collaborative treatment from a team including a mental health professional, dietitian, and GP at a minimum, where the team engaged in high-quality communication and fostered autonomy with limit-setting. Systemic failures negatively affecting team treatment were reported across the care continuum. DISCUSSION: Findings endorse the application of IPCP to outpatient eating disorder treatment as a strategy to improve treatment satisfaction, engagement, and outcomes. Given the paucity of evidence exploring IPCP in this field, however, the development and evaluation of interprofessional education and treatment models is a foundational necessity. PUBLIC SIGNIFICANCE: Team eating disorder treatment is widely used in clinical practice, although there is limited evidence to guide interventions. This study explores attitudes toward and experiences of team outpatient eating disorder treatment among individuals with a lived experience. Understanding preferred team treatment characteristics delivers important information to improve treatment satisfaction, engagement, and outcomes for individuals receiving outpatient eating disorder treatment.

Collaborative dietetic and psychological care in Interprofessional Enhanced Cognitive Behaviour Therapy for adults with Anorexia Nervosa: a novel treatment approach.

Clinical practice guidelines for anorexia nervosa (AN) and atypical anorexia nervosa recommend treatment from a team including a mental health professional and a dietitian. To date, however, AN treatment models such as Enhanced Cognitive Behaviour Therapy (CBT-E) seldom include dietitians and have low to moderate treatment efficacy. Given interprofessional approaches to healthcare have been shown to improve treatment outcomes and enhance patient and clinician satisfaction, formalising collaborative dietetic and psychological treatment may be a feasible strategy to improve treatment outcomes and the patient and clinician experience of treatment. Moreover, malnutrition is a serious consequence of AN, and dietitians are considered experts in its diagnosis and treatment. This paper proposes a novel treatment approach, Interprofessional Enhanced Cognitive Behaviour Therapy (CBT-IE), an adaptation of CBT-E where dietitians deliver content related to malnutrition and dietary restraint and mental health professionals deliver content related to cognitive and behavioural change. The rationale for developing CBT-IE, treatment structure, and future research directions is discussed.

Fidelity to Best Practices in EPA Implementation: Outcomes Supporting Use of the Core Components Framework From the University of Virginia Entrustable Professional Activity Program.

PROBLEM: The rapid expansion of entrustable professional activity (EPA) assessment programs has led to calls to ensure fidelity in implementation and integrity in meeting the goals of competency-based medical education. Initiated in July 2017, in advance of the articulated core components of EPA implementation, this article describes the structure and outcomes of the University of Virginia (UVA) EPA Program and provides support for the identified essential components. APPROACH: The UVA EPA Program includes workplace assessments by residents/fellows, attending faculty, and master assessors (MAs), experienced clinicians who assess students across disciplines and clinical settings. All assessors participate in formal professional development and provide verbal and written comments to support their supervision ratings. The Entrustment Committee, composed of 12 MAs, uses a shared mental model and aggregates all assessor data to make a high-stakes summative entrustment decision about students' readiness to assume the role of an acting intern. OUTCOMES: Since 2017, over 2,000 assessors have completed 56,969 EPA assessments for 1,479 students. Ninety-four percent of assessments have been done during the clerkship phase. Residents/fellows have completed a mean of 18 assessments, attending faculty a mean of 27, and MAs a mean of 882. Seventy-four percent of observed encounters involved patients with acute concerns with or without a co-morbid condition. Fifty percent of assessments occurred in inpatient and 32% in ambulatory settings. Eighty-seven percent of assessments contained narrative comments with more than 100 characters. NEXT STEPS: Planned next steps will include earlier identification of students who require individualized learning to promote the development of skills related to EPAs, expansion of the remediation program to enable more students to engage in a clinical performance mastery elective, and creation of targeted professional development for assessors to reinforce the tenets of the EPA program.

Concordance of Narrative Comments with Supervision Ratings Provided During Entrustable Professional Activity Assessments.

BACKGROUND: Use of EPA-based entrustment-supervision ratings to determine a learner's readiness to assume patient care responsibilities is expanding. OBJECTIVE: In this study, we investigate the correlation between narrative comments and supervision ratings assigned during ad hoc assessments of medical students' performance of EPA tasks. DESIGN: Data from assessments completed for students enrolled in the clerkship phase over 2 academic years were used to extract a stratified random sample of 100 narrative comments for review by an expert panel. PARTICIPANTS: A review panel, comprised of faculty with specific expertise related to their roles within the EPA program, provided a "gold standard" supervision rating using the comments provided by the original assessor. MAIN MEASURES: Interrater reliability (IRR) between members of review panel and correlation coefficients (CC) between expert ratings and supervision ratings from original assessors. KEY RESULTS: IRR among members of the expert panel ranged from .536 for comments associated with focused history taking to .833 for complete physical exam. CC (Kendall's correlation coefficient W) between panel members' assignment of supervision ratings and the ratings provided by the original assessors for history taking, physical examination, and oral presentation comments were .668, .697, and .735 respectively. The supervision ratings of the expert panel had the highest degree of correlation with ratings provided during assessments done by master assessors, faculty trained to assess students across clinical contexts. Correlation between supervision ratings provided with the narrative comments at the time of observation and supervision ratings assigned by the expert panel differed by clinical discipline, perhaps reflecting the value placed on, and perhaps the comfort level with, assessment of the task in a given specialty. CONCLUSIONS: To realize the full educational and catalytic effect of EPA assessments, assessors must apply established performance expectations and provide high-quality narrative comments aligned with the criteria.

The use of EPA assessments in decision-making: Do supervision ratings correlate with other measures of clinical performance?

BACKGROUND: Entrustable professional activities (EPAs) have been introduced as a framework for teaching and assessment in competency-based educational programs. With growing use, has come a call to examine the validity of EPA assessments. We sought to explore the correlation of EPA assessments with other clinical performance measures to support use of supervision ratings in decisions about medical students' curricular progression. METHODS: Spearman rank coefficients were used to determine correlation of supervision ratings from EPA assessments with scores on clerkship evaluations and performance on an end-of-clerkship-year Objective Structured Clinical Examination (CPX). RESULTS: Both overall clinical evaluation items score (rho 0.40; n = 166) and CPX patient encounter domain score (rho 0.31; n = 149) showed significant correlation with students' overall mean EPA supervision rating during the clerkship year. There was significant correlation between mean supervision rating for EPA assessments of history, exam, note, and oral presentation skills with scores for these skills on clerkship evaluations; less so on the CPX. CONCLUSIONS: Correlation of EPA supervision ratings with commonly used clinical performance measures offers support for their use in undergraduate medical education. Data supporting the validity of EPA assessments promotes stakeholders' acceptance of their use in summative decisions about students' readiness for increased patient care responsibility.

Implementing Systematic Faculty Development to Support an EPA-Based Program of Assessment: Strategies, Outcomes, and Lessons Learned.

Problem: Development of a novel, competency-based program of assessment requires creation of a plan to measure the processes that enable successful implementation. The principles of implementation science outline the importance of considering key drivers that support and sustain transformative change within an educational program. The introduction of Entrustable Professional Activities (EPAs) as a framework for assessment has underscored the need to create a structured plan to prepare assessors to engage in a new paradigm of assessment. Although approaches to rater training for workplace-based assessments have been described, specific strategies to prepare assessors to apply standards related to the level of supervision a student needs have not been documented. Intervention: We describe our systematic approach to prepare assessors, faculty and postgraduate trainees, to complete EPA assessments for medical students during the clerkship phase of our curriculum. This institution-wide program is designed to build assessors' skills in direct observation of learners during authentic patient encounters. Assessors apply new knowledge and practice skills in using established performance expectations to determine the level of supervision a learner needs to perform clinical tasks. Assessors also learn to provide feedback and narrative comments to coach students and promote their ongoing clinical development. Data visualizations for assessors facilitate reinforcement of the tenets learned during training. Collaborative learning and peer feedback during faculty development sessions promote the formation of a community of practice among assessors. Context: Faculty development for assessors was implemented in advance of implementation of the EPA program. Assessors in the program include residents/fellows who work closely with students, faculty with discipline-specific expertise and a group of experienced clinicians who were selected to serve as experts in competency-based EPA assessments, the Master Assessors. Training focused on creating a shared understanding about the application of criteria used to evaluate student performance. EPA assessments based on the AAMC's Core Entrustable Professional Activities for Entering Residency, were completed in nine core clerkships. EPA assessments included a supervision rating based on a modified scale for use in undergraduate medical education. Impact: Data from EPA assessments completed during the first year of the program were analyzed to evaluate the effectiveness of the faculty development activities implemented to prepare assessors to consistently apply standards for assessment. A systematic approach to training and attention to critical drivers that enabled institution-wide implementation, led to consistency in the supervision rating for students' first EPA assessment completed by any type of assessor, ratings by assessors done within a specific clinical context, and ratings assigned by a group of specific assessors across clinical settings. Lessons learned: A systematic approach to faculty development with a willingness to be flexible and reach potential participants using existing infrastructure, can facilitate assessors' engagement in a new culture of assessment. Interaction among participants during training sessions not only promotes learning but also contributes to community building. A leadership group responsible to oversee faculty development can ensure that the needs of stakeholders are addressed and that a change in assessment culture is sustained.

Depression symptoms and body dissatisfaction association among polycystic ovary syndrome women.

OBJECTIVE: One publication reported that lower body satisfaction and lower education were independent predictors of depression in polycystic ovary syndrome (PCOS) in women. This study replicates that analysis using different instruments, and adds androgen levels to the model. METHODS: Cross-sectional analysis of questionnaires (Quick Inventory of Depressive Symptomatology-Self-Report, Body Esteem Scale) and serum androgens from a community cohort with (n=94) and without (n=96) PCOS, matched by BMI category. Non-parametric tests, Spearman correlations, and negative binomial regression models were analyzed. RESULTS: Depression symptoms were common (40-60% in lean, overweight and obese BMI categories) in the PCOS cohort, albeit generally of mild severity. The PCOS women had similar depression symptom severity (P>.20) and similar body dissatisfaction (P≥.25) as the regularly cycling women in total and stratified by BMI category. In both the PCOS and non-PCOS cohorts, depression symptom severity was positively correlated with dissatisfaction with physical appearance and physical conditioning (P<.02). Body dissatisfaction (especially perception of physical conditioning) was strongly associated with more severe depression symptoms in non-obese PCOS women (BMI<30, P<.04) before and after controlling for age, testosterone and free testosterone. In contrast, for obese women with PCOS, depression was unrelated to body dissatisfaction after controlling for age. CONCLUSIONS: Among non-obese PCOS women, their subjective body image was strongly associated with the severity of their depression symptoms. Most of the obese PCOS cohort had low body satisfaction and depression symptoms, therefore individual differences in the body dissatisfaction scores were not helpful in identifying depression symptom severity. Neither testosterone nor free testosterone was associated with depression symptom severity in PCOS women after controlling for body dissatisfaction and age.