They are crazy stories, really. It is hard to believe they are true.
How could health care professionals screw up this much? We are not talking about forgetting to do a small and easily overlooked lab test.
What we are talking about is the “omission of an essential therapeutic intervention”: food. “An analogy might be drawn to omitting insulin in the treatment of type 1 diabetes.”
There are a number of possible reasons that, when combined together, lead to these extreme cases of medical negligence. Below is a list ofsome of the reasons that medical personnel might fail to feed, or otherwise care for, patients with anorexia nervosa. This list is taken from a longer list in the paper by Pauline Powers and Nancy Cloak (2012). Some of these reasons might be generalizable to all eating disorders or all mental disorders, whereas others are probably unique to anorexia nervosa.
I think number four and seven are really important. Observing my friends and my partner go through medical school made it very clear for me that, when compared to other facets of medicine, mental health is barely taught. The disparity is striking given that mental health issues affects nearly everyone, directly or indirectly. It is not something reserved for a particular group of individuals deemed “crazy.”
Powers and Clark wrote that when it comes to eating disorders,
Clinicians may not understand the mental processes that interfere with the patient’s ability to eat appropriately. This kind of response may relate not only to lack of information, but also to a kind of collusion with the patient’s denial of illness, or to a misunderstanding of eating disorders as caused by societal pressures for thinness.
There is a tendency–a desire that I think all of us have–to think of physicians and surgeons as always acting in the best interest of the patient. But that’s not always true. It is not true for many reasons, but from the list above, two broad categories appear: (1) lack of knowledge and (2) countertransference reactions.
Countertransference, as Wikipedia defines it, is “a redirection of a psychotherapist’s [or physician’s] feelings toward a client—or, more generally, as a therapist’s [/physician’s] emotional entanglement with a client.”
Think number thirteen or fourteen.
When it comes to knowledge about eating disorders or how to treat them, physicians don’t do so well:
- 42% of primary-care physicians felt they didn’t have the skills to screen for EDs, according to a US survey (Linville, Brown, & O’Neil, 2012)
- 72% were uncertain about how to managed patients with EDs (Linville, Benton, O’Neill, & Sturm, 2010)
- 42% of Ob/Gyn’s in the UK and Australia over-estimated the weight loss required for the anorexia nervosa diagnosis (J. F. Morgan, 1999), and in one UK survey, 53% of primary care physicians thought a BMI of 16 or less was required for the diagnosis of AN (Currin, Waller & Schmidt, 2009)
- 25% thought bulimia nervosa was untreatable (J. F. Morgan, 1999)
Adding to the general lack of knowledge about eating disorder diagnosis and prognosis is the bad reputation that ED patients have among health care professionals. Clinicians and therapists often feel envious, frustrated, and helpless when it comes to treating patients with EDs. Patients are often seen as being weak and manipulative (J. F. Morgan, 1999). The perceptions of nursing staff, therapists, and physicians are similar to that of the general public: patients with anorexia nervosa are not really sick. They are attention seeking, bratty, middle-upper class white girls. Nothing, of course, could be further from the truth.
In 1977, H.G. Morgan wrote in an article titled “Fasting girls and our attitude toward them” about countertransference:
We are of course anxious to feed those who take insufficient food, but if frustrated, our anxiety quickly turns to hostility at what seems to be an unnecessary, self-imposed disease . . . . we need to come to terms with [this] if our treatment is to be more effective than our predecessors.
I’m not in the healthcare profession, and I’m not old enough to know how much things have changed. But I do know that more needs to be done. A lot more.
Powers and Cloak provide some advice–tailored not at specific individuals but at health care institutions more broadly–about how to minimize the risk of the medical errors such as those described in the stories above. I summarized their suggestions in the figure below:
This list is just skimming the surface. It is aimed at physicians and health care workers in hospitals or other health care institutions. It is aimed at working professionals and what they can do now. There are many more things that need to be addressed at the training level for physicians, nurses, therapists, social workers, and so on. We need more education for families and carers about how they can work together with their loved ones and the healthcare team to facilitate recovery.
Finally, I think we need to work toward a better public understanding of eating disorders. I want to see more stories about eating disorders in the medicine, health, and science sections of newspapers and magazines, as opposed to the fashion and celebrity news sections.
Naturally (because I write this blog), I think that for better eating disorder treatment and care, we need more research findings to get into the hands of clinicians and health care workers, parents, patients, and the general public. (Of course, these issues are not unique to eating disorders, and I would never imply that they are.)
As an aside, this is probably (99% likely) my last post for 2012. Happy New Year! And as always, thank you so much for reading, commenting, tweeting, sharing, and sending me lovely messages about how much you enjoy the blog. It means so, so much to me!
Powers, P., & Cloak, N. (2013). Failure to Feed Patients With Anorexia Nervosa and Other Perils and Perplexities in the Medical Care of Eating Disorder Patients Eating Disorders, 21 (1), 81-89 DOI: 10.1080/10640266.2013.741994