The UPMC Palliative and Supportive Institute (PSI) participates in many community, educational, and professional events, throughout the Pittsburgh area and around the country. We invite you to contact us to learn more.
Andrew Thurston, MD received the Carl R. Fuhrman Clinical Educator of the Year Award.
Jessica Merlin, MD, PhD and Robert M. Arnold, MD are contributors to an expert consensus statement on managing advanced cancer-related pain with co-occurring opioid use disorder, which stems from Dr. Merlin's Delphi study. View the statement in the JAMA Network Open here.
Fueled by the Palliative Research Center (PaRC) and Hillman Cancer Center, the work to close gaps in access to palliative care continues. Currently, the CONNECT project is examining data from a trial in which oncology nurses across 17 UPMC community oncology practices were empowered to initiate primary palliative care interventions.
The Palliative Research Center (PaRC) at the University of Pittsburgh is contributing to research in this area.
Lindsay Bell Abdulhay, MPH, a research project coordinator with PaRC , participated in a recent GeriPal podcast on the lack of diversity in palliative care. She discussed research specific to how this deficit manifests itself in medical school curricula at historically black colleges and universities (HBCUs).
Research reveals that HCBUs with the highest percentage of Black and underrepresented people have little to no curriculum on palliative care. This is a considerable hurdle in the effort to reduce health disparities in palliative care.
Through the ExPERT (Expanding Palliative Education Research and Training) project, PaRC is leveraging partnerships between the University of Pittsburgh and three minority-serving medical schools to expand palliative care training opportunities for learners from underrepresented schools. This is resulting in mentorship for students and educational tools and training for both learners and faculty related to palliative care.
“Hopefully, with more collaboration and action, the future for palliative care medical professionals will be more diverse,” says Lindsay.
As the director of the CHAllenges in Managing and Preventing Pain (CHAMPP) clinical research center, Jessica Merlin, MD, PhD, MBA brings her expertise in palliative care, pain management, and opioid use disorder to improve care for individuals with serious illness.
Dr. Merlin’s Delphi study was designed to learn how to best manage patients who have advanced cancer-related pain, often managed with opioids, who also experience challenges with opioids like opioid misuse or use disorder.
Dr. Merlin hopes that the results of her Delphi study will help front-line clinicians better manage patients in these difficult situations. Many groups around the country collaborated in this study, including palliative care at UPMC.
This study was funded by Cambia Health Foundation and was completed in the summer of 2020. Results will be published imminently in JAMA Network Open.
Additionally, Dr. Merlin is collaborating with Julie Wilson Childers, MD, MS, FAAHPM in the Palliative Recovery Engagement Program (P-REP). Dr. Merlin and Dr. Childers operate an outpatient clinic within the larger Internal Medicine Recovery Engagement Program at UPMC Mercy. The clinic sees patients with palliative care needs who also have a substance use disorder.
As Dr. Childers explains, “Typically, these patients don’t do well on opioids without careful management and suffer increased pain from cancer and its related treatments. They also carry anxieties about relapsing. Previously, these patients had no dedicated medical team and often fell out of care.”
Launched as a pilot program in 2020, the clinic is staffed by nursing, social work, and peers in recovery. Patients meet regularly with clinicians both in person and virtually. The clinic has treated 26 patients since its inception.
This home-based program is for UPMC Health Plan members who have a serious or advanced illness. Advanced Illness Care (AIC) helps adult patients to better cope with their illnesses and maintain the highest possible quality of life. A nurse practitioner, RN care coordinator, and a social worker, all expert in palliative care, can make consultative visits to the patient in the home, in person or virtually. This team can work with the patient’s physician to assist with managing comfort, decision making related to care based on the patient’s goals and values, providing emotional support, and exploring additional resources to help with care.
Scroll down to view a video, funded by the Millbank Foundation, to learn more about Advanced Illness Care.
To refer a patient, call 1-800-493-3760 or email the UPMC Health Plan.
Narrative medicine bridges storytelling and medicine to enhance the care of the patients. Andrew Thurston, MD, believes the heart of palliative care and narrative medicine intersect at the human story. It is more than health conditions and diagnosis; it’s the need to get to know our patients which ties us together.
Narrative medicine benefits both patients and health care professionals. Residencies and fellowships are tough. Difficult and devastating situations happen in the field that health care workers must navigate, while everyone has their own lives happening in the background. Suppression of emotions and experience is unhealthy. As Dr. Thurston describes it, “it’s easy to push the bad away, but you should be checking in with yourself.” When Dr. Thurston teaches the palliative care fellows, they analyze paintings, poetry, short stories, essays, complete reflective exercises, and prompt questions. This helps learners focus on their personal experience in medicine and meet with patients on a more human level. A prescription to read literature aloud to a patient or write about an experience can bring genuine palliation.
Dr. Thurston preaches reflection on challenging situations and talking to peers in a safe environment. He strives to create a trustworthy environment in his classroom when he teaches narrative medicine as an elective to those in their third or fourth year of medical school. Dr. Thurston recognizes the benefit of this elective for both medical students and their future patients. The students can talk freely and read narrative essays and poetry. The elective invites facilitators into the classroom and, during the writing workshop, a published author joins the class. Dr. Thurston observes how the medical students really show their creative side, a creativity that may have been otherwise dormant during their studies.
In bridging humanities and palliative care medicine through narrative medicine, “we have the opportunity to maximize what it means to be human,” says Dr. Thurston.
Read a reflection from Dr. Thurston here.
Karl Bezak, MD, provides an overview of palliative care and how COVID-19 brings to light the importance of advance care planning.
The newly dedicated Tara E. Cook Hospice and Palliative Medicine Annual Teaching Award has been presented to Rene Claxton MD, MS.
The University of Pittsburgh’s Section of Palliative Care and Medical Ethics is honored to announce the dedication of its annual teaching award to Tara E. Cook, MD, MS. In 2016, Dr. Cook joined UPMC to complete her hospice and palliative medicine fellowship as well as her master’s degree in medical education. She joined the faculty subsequently. Sadly, Dr. Cook died in May of this year.
Although Dr. Cook’s time was far too short, she distinguished herself as a compassionate physician with outstanding clinical skills who was fully dedicated to her patients, colleagues, and trainees. In 2020, she received this same teaching award in recognition of her dedication and commitment to the field of palliative care. The Section hopes to bring honor to Dr. Cook’s legacy and to future award recipients by officially naming the award after her.
Dr. Claxton, this year’s awardee, served as the hospice and palliative medicine fellowship program director for eight years from 2012 to 2020 and now serves as the associate medical director for community palliative care within the UPMC Palliative and Supportive Institute. Dr. Claxton oversees the Section’s educational portfolio. Additionally, she is senior faculty for the national communication program, VitalTalk, and has helped build many of the palliative care communication programs for specialties ranging from geriatrics to critical care medicine. She has distinguished herself as a compassionate and dedicated teacher and has mentored countless trainees.
In her nomination for the award, Dr. Claxton was described as a “fantastic teacher, providing focused education sessions and frequent, timely feedback after patient interactions. Her passion and skill at teaching are apparent.”
An interview with Nisha Bowman, LSW, UPMC palliative care social worker, UPMC Presbyterian Shadyside, sheds light on palliative care, how it differs from hospice, and the impact of COVID-19 on the dying experience.
Ashley Wills, CRNP, palliative and supportive care, UPMC Magee-Women’s Hospital, is the inaugural recipient of the UPMC Advanced Practice Practitioner Rising Star Award, recognizing outstanding team-based patient-centered care.
Four palliative care physicians were recipients of Physician THRIVE, the UPMC Physician Excellence Award, including Karl Bezak, MD (New Physician Excellence Award); Andrew Thurston, MD (Early-to-Mid-Career Physician Excellence Award); Linda King, MD (Senior Physician Excellence Award); and Scott Miller, MA, MD (Senior Physician Excellence Award). The award recognizes high level of engagement, exceptional teamwork, noteworthy innovations, and the advancement of UPMC’s clinical mission and values.
Julie Childers, MD, MS and Jane Schell, MD have been appointed to the University of Pittsburgh School of Medicine’s Academy of Master Educators. The Academy of Master Educators recognizes and rewards excellence in education, strives to advance education through innovation and professional development of faculty, and supports and promotes educational scholarship.
Heather Mikes, DO, received the 2021 UPMC McKeesport Family Medicine Teaching Attending of the Year Award.
Jonathan Perlman, BCC, HD.Div., palliative care bereavement and spiritual care coordinator, UPMC Shadyside, has been presented with an honorary doctorate from the Jewish Theological Seminary (JTS). This honor expresses appreciation and admiration for Rabbi Perlman’s achievements as someone who has served the Jewish community and the Conservative movement with distinction for more than 25 years.
Lindsay Bell Abdulhay, MPH, a research project coordinator with the Palliative Research Center (PaRC), was lead author for an article published in the Journal of Pain and Symptom Management on diversity in palliative care and training for learners in historically Black colleges and universities. Robert M. Arnold, MD and Yael Schenker, MD, MAS were also contributors to the piece. View the article here.
Robert M. Arnold, MD and Yael Schenker, MD, MAS are contributors to an article in the Journal of Clinical Oncology, Oncology Practice regarding advance care planning and hope in the case of advanced cancer. View the article here.
Becca Hoelsken, CRNP, UPMC Palliative and Supportive Institute, and her UPMC Shadyside colleagues in nursing and administration recently coordinated a visit from two horses and a dog on behalf of a dying patient.
In conversations with Diane, the patient, who was recovering from COVID-19 and newly diagnosed with metastatic brain cancer, Becca learned that she cherished her pets, including two cats, a dog, and a horse named Jorden. Diane had ridden Jorden for more than 20 years, but the horse was retired and now boarded at a nearby farm. Becca recognized Diane’s deep sadness around the absence of these important relationships. She reached out to hospital administration late one Friday afternoon to request permission for an outdoor visit from the patient’s horse on hospital grounds.
Forty-eight hours later, on a Sunday afternoon, Diane was transported outside to the hospital courtyard where Jorden, a miniature support horse for Jorden named Timbuck, Diane’s dog, Princess, and several family members were gathered for a visit. Those present, including Becca, noted that multiple patients watched from their own windows above, and a physician delivered apples for the horses.
Those who participated in the experience expressed deep gratification at having brought comfort to Diane as her days drew to a close. Acting upon what was still possible and meaningful, even when death was near, made a difference for this patient and for her family.
Initiatives addressing these issues extend throughout palliative care from teaching to research to interactions with our colleagues and our community.
Eva Reitschuler Cross, MD participates in an anti-racism and social justice committee comprised of about ten PSI staff and faculty colleagues. She acknowledges that recent events including the killing of George Floyd and the COVID-19 pandemic have compelled many to move past outrage to action. “We are pursuing how we can educate ourselves and how we can engage others in a meaningful, sustained manner around these huge societal problems.”
In the realm of education and training, Robert Arnold, MD, FAAHPM and Yael Schenker, MD, MAS, FAAHPM are leading the Expanding Palliative Education, Research and Training (ExPERT) Program. This program partners with three minority-serving institutions: Morehouse School of Medicine, Howard University, and the University of Puerto Rico to implement a palliative care curriculum for medical students, residents, and fellows. It also provides resources and training for their faculty to build a sustainable palliative care educational infrastructure within their program.
Locally, Rebecca Sands, DO, program director for the Hospice and Palliative Medicine Fellowship, reports a rising interest among fellows related to a curriculum on diversity; this will be implemented in the next academic year.
Dr. Jessie Merlin, MD, PhD, MBA is part of the Rapid Response Team assembled by the dean of the School of Medicine at the University of Pittsburgh to address racism and xenophobia. Additionally, she and her colleague, Maya Ragavan, MD MPH, MS, are spearheading a research initiative to develop anti-Black racism interventions for non-Black faculty. “My hope is that we can develop an intervention that engages non-Black faculty in improving the well-being and existence of Black faculty in the medical school space. Previous diversity and inclusion efforts have left Black faculty alone, largely. This puts the weight of executing changes on non-Black faculty,” explains Dr. Merlin.
In terms of community outreach, Rabbi Jonathan Perlman, chaplain and bereavement and spiritual coordinator for PSI at UPMC Shadyside, has been engaged with the leadership of Rodman Street Missionary Baptist Church for many years. The church has a large lay ministry program to provide support to homebound, ill congregants in health care facilities. Says Rabbi Perlman, “Despite what reports show about inequities in the health care system, Black churches promote full wellbeing and use their ministry to educate their members. It is a spiritual directive.”
Working with the church leadership, Rabbi Perlman, palliative care social worker Tanisha Bowman, and Drs. Keith Lagnese and Richard Weinberg surveyed the lay ministers about their attitudes and knowledge pertaining to hospice and palliative care. While members had considerable positive experiences with hospice, the survey showed concerns about costs, services at home, palliative care, and quality of care at the end of life. The PSI team addressed these concerns in a one-hour virtual conference, connecting with 39 members of the church. Future efforts will build on this foundation in working with other churches and groups serving the Black community. “The goal is to undo systemic racism within the health care arena,” says Rabbi Perlman.
With funding from UPMC Presbyterian, Karl Bezak, MD is leading the implementation of a Schwartz Rounds series. This recutting interdisciplinary forum will provide an opportunity for all health care professionals at UPMC Presbyterian to connect and share their experiences in caring for patients and families dealing with serious illness.
Says Dr. Bezak, “It’s a safe, confidential space for all health providers to meet and learn more about each other’s roles, stresses, and successes to share in a common humanity and foster compassion and collaboration.”
This forum is intended to enhance provider understanding, collaboration, wellness and resilience as they strive to provide high-quality, compassionate care to patients and their families. The launch is planned for early 2021.
Chandler Mitchell, a University of Pittsburgh medical student, received an award from The Alan Gleitsman Student Research Fund in Palliative Care, which provides $3,000 for summer learning in the Palliative Care Program.
Under the guidance of Yael Schenker, MD, Chandler is researching the role and impact of shared care plans (SCPs) in a primary palliative care intervention (CONNECT) for patients with advanced cancer.
“I have worked on the CONNECT trial since 2016,” Chandler said. “My interest in the effects of SCPs originated through my work evaluating audio recordings of CONNECT visits. SCPs foster a collaborative dialogue between CONNECT nurses and patients to identify one or more symptoms and create a treatment plan based on each patient’s individual needs and lifestyle.”
In the years since Chandler has been working with Dr. Schenker, he has continuously pursued clinical and research opportunities with her team.
“My experiences on the CONNECT trial and working alongside Pitt palliative care physicians have shaped my view of medicine and how I envision my future within it,” Chandler said. “This project will allow me to develop my clinical research skills under Dr. Schenker’s mentorship. And, it will help me further understand the unmet needs faced by patients suffering from advanced illness and the effect of primary palliative care on improving their quality of life.”
Like so many, Karl Bezak, MD and Taylor Lincoln, MD want to do everything they can to alleviate the suffering of patients, families, and colleagues impacted by the COVID-19 pandemic. Both are among a group of ten UPMC and University of Pittsburgh palliative care physicians who readily offered their services when Robert Arnold, MD, FAAHPM, medical director for the UPMC Palliative and Supportive Institute (PSI), reached out to solicit help from among his colleagues on behalf of the Mt. Sinai Health System.
With more than 16,000 deaths to date, the people of New York City have been the hardest hit by the pandemic. As Dr. Bezak expressed, “While we were bracing for the storm here in Pittsburgh, New York City was in it.” Dr. Lincoln noted that administrative leadership from both Mt. Sinai and UPMC worked with incredible agility to accelerate physician credentialing and make this collaboration possible.
The clinical support takes two forms, both virtual. Our palliative care physicians are participating in goals of care conversations with patients, families, and colleagues in the inpatient setting. Additionally, Mt. Sinai is operating “PATCH-24,” a telephone hotline fielding inquiries related to palliative care and COVID-19. Physicians can help identify a primary decision-maker to speak on the patient’s behalf should he or she become unable to do so; this may involve patients who are symptomatic and still awaiting diagnosis.
Clearly, the practice of medicine is being transformed by COVID-19. Both Dr. Bezak and Dr. Lincoln see its current and future impact as it pertains to palliative care. “Without enough palliative care specialists to meet the demand, telemedicine can help increase patient and family access,” says Dr. Lincoln. Dr. Bezak agrees that virtual interventions can bring needed services to existing “palliative care deserts.” Additionally, he anticipates that telemedicine will be incorporated across core competencies for physicians-in-training.
View this video produced by local physicians as a gesture of support for their colleagues.
MusiCare, a University of Pittsburgh School of Medicine student volunteer initiative, has gone virtual to adapt to the COVID-19 pandemic.
With guidance from faculty advisor Jane Schell, MD FNKF, medical students early on in their training and faculty who are also musicians and vocalists have created a YouTube channel, MusiCare Connections, featuring recorded performances intended to provide connection and comfort to patients.
Since 2014, MusiCare volunteers have been performing in UPMC hospital settings including UPMC Children’s Hospital and the dialysis unit at UPMC Presbyterian, gathering monthly to lend a human touch to patients’ clinical experiences.
Awarded annually, this fellowship affords an opportunity for mentoring in the field of clinical social work for candidates with previous clinical experience who wish to specialize in palliative care. This is a one-month clinical rotation at UPMC Presbyterian and Family Hospice, part of UPMC. Apply here (PDF). The deadline for applications is April 15, 2020.
Tanisha Bowman, LSW, Palliative and Supportive Care, UPMC Presbyterian, has been honored with the Kristin Bowser Emerging Social Work Leader Award by the Pennsylvania chapter of the National Association of Social Workers.
Robert Arnold, MD, FAAHPM has been recognized by AAHPM with the 2021 Award for Excellence in Education and Training. Dr. Arnold is the first recipient of this award.
Dr. Rachel Rodenbach, a fellow in the Section of Palliative Care and Medical Ethics, was recognized by the American Academy of Hospice and Palliative Medicine for her top scoring Quality Improvement research and poster submission. Dr. Rodenbach completed this project under the mentorship of Dr. Julie Childers.
Julie Wilson Childers, MD, MS, FAAHPM, is the 2020 recipient of the Mid-Career Physician Award, one of only five physicians to be honored with a Hastings Center Cunniff-Dixon Physician Award for exemplary service to patients near the end of life. Dr. Childers is medical director of the palliative care service at UPMC Presbyterian and is senior associate with VitalTalk. Her writing and teaching work has focused on goals-of-care discussions and managing addiction among patients who are nearing the end of life.
Julie Childers, MD, MS, FAAHPM participated in a panel discussion on behalf of the National Academies of Sciences, Engineering, and Medicine. Hear Dr. Childers’ contribution to the two-day workshop on Quality Care for People with Serious Illness beginning at minute 58.
Robert Arnold, MD, FAAHPM and Jane Schell, MD FNKF co-authored “There Is No I in Team: Building Health Care Teams for Goals of Care Conversations” which appeared in the Journal of Palliative Medicine.
Judith Resick, MSN, MPH, RN and Dr. Schenker collaborated on Primary Palliative Care for Patients with Advanced Hematologic Malignancies: A Pilot Trial of the SHARE Intervention, also in the Journal of Palliative Medicine.
Robert Arnold, MD, FAAHPM contributed to this piece from the Annals of Internal Medicine. He and his VitalTalk co-authors contend that “it is possible to get better at facing inequality, suffering, and dying, regardless of the circumstances.”
The UPMC Palliative and Supportive Institute received a $250,000 award to address cultural disparities in providers trained and skilled in palliative care. Learn more.
Avery Meltzer, medical student at the University of Pittsburgh, has been presented the 2019 Gleitsman Award, which provides $3,000 towards summer learning in the Palliative Care Program. Avery is being mentored by Dr. Janel Hanmer in a research project that evaluates whether patients enrolled in the Enhanced Care Program (ECP), a chronic care management program serving complex patients, experience a change in Health-Related Quality of Life (HRQoL) as a result of their participation in the program.
This project is part of a larger body of research being conducted at UPMC to establish a set of generic HRQoL metrics that can be used comparatively to assess patient outcomes across different health settings.
Avery plans to become a primary care physician and aspires to find solutions for underserved families to address the chronic illnesses that disproportionately affect them.
Dr. Robert M. Arnold mentors physicians, pharmacists, social workers and medical ethicists as part of the Jewish Healthcare Foundation's Death and Dying Fellowship, featured in the Pittsburgh Post Gazette.
Co-sponsored by UPMC's Family Hospice and Palliative Care and the UPMC Palliative and Supportive Institute, this year’s symposium brought together more than 150 physicians, physician assistants, social workers, and nurses to discuss strategies and resources to improve the patient experience for the seriously ill, as well as for their families.
Topics included expanded access, end stage renal disease care, and integrative oncology advancements. Dr. Karen Hacker, medical director for the Allegheny County Health Department, spoke to health care disparities.
Planning is underway for a fall symposium in Altoona.
Emily Svitek, University of Pittsburgh master’s in social work candidate, is the recipient of the 2019 Amdur Fellowship in Palliative Care. Awarded annually, this fellowship affords an opportunity for mentoring in field of clinical social work, specific to patients living with serious, traumatic, and/or chronic illness.
Emily is being mentored by Natalie A. Magoc, LSW, Collaborative Care Management at UPMC Presbyterian. Natalie was herself an Amdur Fellow and hopes to impart skills in how to best support patients and their families, including having difficult conversations about end of life.
Dio Kavalieratos, PhD, assistant professor of medicine, Palliative Care and Medical Ethics, University of Pittsburgh, and director of Implementation Research for the UPMC Palliative and Supportive Institute, has been awarded the 2019 American Academy of Hospice and Palliative Medicine (AAHPM) Early Career Investigator Award. This award recognizes Dr. Kavalieratos as a developing research leader, who shows promise in making contributions to the development of a scientific foundation for practice and research, and who conducts and facilitates research by others that advances the field of hospice and palliative medicine.
Dr. Kavalieratos is the first PhD to ever win this award. Recently, he has completed research and policy work integrating specialty palliative care into the care of patients with cystic fibrosis and conducted a trial with primary palliative care intervention for patients with advanced heart failure.
The Palliative and Supportive Institute served as a sponsor for the Memory Tent at the National Ovarian Cancer Coalition Walk. More than 130 families visited the tent for information on palliative care and bereavement resources. Staff from PSI collaborated with peers from Family Hospice and Palliative Care in providing support to individuals, families and caregivers.
The Palliative and Supportive Institute has been named a winner of the 10th anniversary Fine Award for commitment to excellence in safety, quality, efficiency, and innovation.
In this anniversary year, institutions previously recognized were considered for an additional award based on sustained and expanding growth of the program to other departments within their organization.
Jennifer Pruskowski, PharmD, pharmacist, Palliative and Supportive Institute, has been selected as the 2018 ACCP New Clinical Practitioner Award winner. This award recognizes a person who, after less than six years since completion of training has made outstanding contributions to the health of patients and to the practice of clinical pharmacology.
The ASP Eric G. Neilson, MD, Distinguished Professor Award is presented annually to a physician who has demonstrated outstanding leadership and support of specialty internal medicine. This year's recipient is Dr. Robert M. Arnold, Medical Director of the UPMC Palliative and Supportive Institute. Dr. Arnold received the award at a March 2018 reception in San Antonio, Texas.
The University of Oklahoma College of Medicine selected Dr. Robert M. Arnold, Medical Director of the UPMC Palliative and Supportive Institute, as recipient of the Patricia Price Browne Prize in Biomedical Ethics. This honor recognizes Dr. Arnold for his expertise in palliative care and doctor-patient communication. Learn more about the Biomedical Ethics Prize.
A group of medical students, lead by Sae Jang, volunteered to play music for patients at UPMC Presbyterian. Palliative care physician Dr. Jane Schell helps the students connect with the right patients. Read the full article and watch a video from KDKA.
Dr. Jane O. Schell, palliative care physician at UPMC Presbyterian and Shadyside hospitals, co-authored an article addressing communication and cultural competence as it relates to shard decision-making. It was published in the Clinical Journal of the American Society of Nephrology. Read the article.
Jennifer Pruskowski, PharmD with UPMC's Palliative and Supportive Institute and the University of Pittsburgh, participated in the 2016 Sino American Forum of Clinical Pharmacy in Shanghai, China. Jennifer presented on the topic of "Palliative Clinical Pharmacy Care in the United States."
Dr. Andrew Thurston, a UPMC Palliative and Supportive Institute physician at UPMC Mercy, recently had an opinion piece published in the Journal of American Medical Association. Read the reflection here.
The Pittsburgh Post-Gazette recently featured an in-depth story on the nature and benefits of palliative care for seriously ill patients. Read the story and watch the accompanying video interview with Robert Arnold, MD, Medical Director of the UPMC Palliative and Supportive Institute.
Dr. Robert M. Arnold, Medical Director of the UPMC Palliative and Supportive Institute discussed palliative care, end-of-life issues, and how better communication can help patients, families, and their caregivers that are facing a serious illness or end-of-life concerns. Listen to the 30 minute discussion.