Is the Doctor in? Eating Disorders Training Amongst Medical Professionals — Part 1

Something that has often shocked and, frankly, appalled, me is how little training exists for those at the front line of eating disorder service delivery. I’m talking about people like family doctors, teachers, coaches, and others who might act as key gatekeepers for eating disorder services; those who don’t make eating disorders the focus of their practice but who likely encounter people with eating disorders as a part of their work life.

When I hear horrible stories about doctors shrugging off symptoms of eating disorders because the person presenting to the office does not “look like they have an eating disorder,” I want to cry. When I talk to teacher friends about the lack of built-in training around eating disorders (sometimes they have sought out opportunities to enhance their mental health awareness, but these don’t tend to be built in), I wish I had more to offer them. When I listen to young athletes talk about their coach’s prescribed low-carb diet for the team, I want to scream.

It becomes clear to me, through these encounters and others, that we could be doing more to equip more people with the knowledge they need to deftly navigate the rocky terrain of eating disorders. As one does, I took to the literature to discover what is going on, training wise, and how this might impact encounters on the front line. I found that, perhaps surprisingly, there are few specialized training opportunities even for those who are later on in the treatment continuum, including psychiatrists with an interest in treating eating disorders. As I began to scour the literature, it became increasingly clear to me that this was not going to be a short post. I decided to focus on medical professionals, because I’ve written about teachers before (and will write about coaches in the future!).

In the interest of not putting you to sleep, I will separate the post into 3 parts. People have been writing about the lack of eating disorder training for medical professionals across the continuum for quite some time; one of the studies I’ll include in this series began in 1990. And yet, thre seems to be little movement in this area; the article that first sparked my interest in reviewing the literature is from 2015.

An Overview on the State of Eating-Disorder-Related Training for Medical Providers

As one might expect, there are differences between countries in terms of what kind of training they provide to medical professionals. In this series I’ll focus on the US, the UK, and Canada, because the articles I found relate to these countries in particular. But for anyone interested in this kind of research, it would be amazing to be able to meaningfully compare across international contexts. Voila, insta-PhD!

To briefly summarize what I found, it would appear that:

  • There are very few programs for medical professionals that provide built-in training for eating disorders specifically (Mahr et al., 2015; Girz, Lafrance Robinson & Tessier, 2014)
  • Those programs that exist may or may not prepare clinicians to address eating disorders (Jones & Larner, 2004)
  • Even in psychiatric programs, where you might imagine there is a higher degree of attention paid, psychiatric residents emerge feeling underprepared to face the realities of treating eating disorders in all of their complexities (Jones, Saeidi & Morgan, 2013; Williams & Leichner, 2006)
  • Medical professionals in the eating disorder field are prone to burnout due to the high demands of the job and relative lack of training and support for eating disorders (Warren, Schafer, Crowley & Olivardia, 2013)
  • Consequently, we need to create more training opportunities, networks, and support for medical professionals dealing with eating disorders, whether this is their specialty or not

Kind of a bleak state of affairs, am I right? Before becoming too dejected, let’s get into some of the literature in more detail. In this first post I’ll focus on training amongst an interdisciplinary group of medical professionals; in the next I will focus on training for psychiatrists and for those wanting to specialize in eating disorders in particular. In a third post, I will comment on the potential for burnout amongst treatment providers in this field, to highlight the need to provide more support for the next generation of eating disorder professionals (not to mention those currently in practice!). I’ll also bring these areas together against our current socio-cultural-political-economic to comment on implications of this state of affairs.

Training for Medical Professionals in the US

The article that first sparked my interest for this post is by Mahr et al. (2015), who wanted to find out whether and how eating disorder training is provided in medical residency programs. They sent out the survey to medical training programs across 5 disciplines:

  • Family medicine
  • Internal medicine
  • General psychiatry
  • Pediatrics
  • Child and adolescent psychiatry

They received 596 full and 42 partial (for a total of 637) responses. Out of these, 514 of the programs had no rotations specifically for eating disorders. I don’t know about you, but I find that more than a little scary. On the bright side, there appear to be at least 42 programs in the US in these disciplines that do offer scheduled eating disorder rotations, and 81 offer these as an elective rotation.

Now, I have to give the benefit of the doubt that at least part of this gaping hole may be due to not having specifically eating disorder-oriented units in the hospitals where these residencies are taking place. If this is the case, it is much harder to offer a rotation in which the medical students could learn by working with eating disorder patients. Still, the data these authors present points to the overwhelming lack of attention paid to eating disorders in medical school curricula.

For example, 113 general psychiatry programs responded to the survey. Of these:

  • 35 offered rotations in eating disorders
  • The average length of rotation was 1-3 months
  • Only 7 programs were at the higher end of this length of time (18 had month-long rotations and 10 had less-than-month-long rotations)

In family medicine, 201 programs responded to the survey, and:

  • Only 25 offered ED rotations
  • Similarly to general psychiatry, these were most commonly month or less-than-a-month long

Of course, this length of rotation commonality leads me to believe that this is “the usual” rotation length, no matter the specialty. Unsurprisingly, larger programs had more on offer in terms of teaching about eating disorders via medical training rotations.

Perhaps more distressing than the lack of rotations, which I’m willing to partially consider a function of the lack of eating disorder services in hospitals providing medical training (or, at least to say that the lack of services in general is a topic for another post and another rant), is that 14.5% of the programs surveyed offered nothing in terms of formal teaching around eating disorders. For those that did:

  • Internal medicine offered an average 1.94 hours of teaching about eating disorders
  • General and child/adolescent psychiatry provided an average of 4 hours of teaching
  • Family medicine provided an average of 3.55 hours of teaching
  • Pediatrics, which offered the most offered 5.25 hours, though some programs offered significantly more, up to 120 hours

The authors note that there are a number of reasons why training in eating disorders might be lacking, among them:

  • Few experts able to provide training and supervision
  • Geographic disparities
  • Lack of standardized guidelines

While I can understand that it is better to learn from the experts, the first point in particular irks me: if we aren’t training up a new group of experts, will this situation not just get worse and worse? Particularly in light of the significant burnout associated with working in the eating disorder field, we need to be conscious of creating a group of medical professionals equipped to handle the complexity of eating disorders.

The situation is not entirely a lost cause, of course; the authors suggest that technology, for example large online courses (MOOCS), web-based training, and collaboration with organizations like the Academy for Eating Disorders may be helpful.

A Canadian Example: Is it Any Better North of the Border?

Of course, people tend to malign the US medical system and joke about moving to Canada for better health care. While I could go into detail about flawed assumptions about our healthcare system, I’ll let the following study speak for itself in terms of drawing commonalities in terms of at least training environments for medical professionals.

Girz, Robinson & Tessier (2014) distributed a survey amongst 880 participants completing postgraduate training in medicine in the following fields (in order of most participants to least):

  • Family medicine
  • Psychiatry
  • Internal medicine
  • Pediatrics
  • Obstetrics and gynecology
  • Emergency medicine

Unlike the previous study, this one focused on training in child and adolescent eating disorders specifically. The most important finding for our purposes here is that the majority of participants (70%) had received 5 hours or less training in eating disorders amongst children and adolescents. Looking at what they did and did not learn (or learn enough about) in these 5 hours or less, over half of the residents surveyed indicated that they would have liked more training in:

  • Early identification, screening
  • Medical assessment
  • Outpatient management
  • How to determine what is an eating disorder (vs. disordered eating, vs. normal eating)

It is important to note (as the authors do) that many survey-takers were in the first year of residency, which may partially explain the extreme lack of training and exposure to eating disorders. However, residents have already been through medical school, which makes this result still a striking one. Given that these residents were not exposed to much training in eating disorders, many unsurprisingly performed quite poorly on a test of knowledge about treating eating disorders in children and adolescents. Residents were not terribly comfortable with managing/treating eating disorder, especially EDNOS.

Similarly to the results from Mahr et al., residents in pediatrics received the most training. Additionally, psychiatry residents in this study received more training than other specialities (with the exception of pediatrics). Girz et al. note that even a slight increase in training hours and exposure improves knowledge of and comfort in treating eating disorders, but that knowledge and competence amongst residents with slightly more training was still less than desired.

While these results are quite discouraging, both of these articles help to indicate the need for increased training quite convincingly. Clearly, more time needs to be devoted to teaching about eating disorders in an effective way. But what is an effective way, and how do we know what works? In the next post, I’ll highlight a Canadian study on psychiatrist satisfaction with eating disorder training. I’ll also touch on comfort and skill in treating eating disorders in an inter-professional group in the UK.

References

Girz, L., Robinson, A., & Tessier, C. (2014). Is the Next Generation of Physicians Adequately Prepared to Diagnose and Treat Eating Disorders in Children and Adolescents? Eating Disorders, 22 (5), 375-385 DOI: 10.1080/10640266.2014.915692

Mahr, F., Farahmand, P., Bixler, E., Domen, R., Moser, E., Nadeem, T., Levine, R., & Halmi, K. (2015). A national survey of eating disorder training International Journal of Eating Disorders, 48 (4), 443-445 DOI: 10.1002/eat.22335

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Andrea

Andrea is a PhD candidate focusing on individual, familial, and health care definitions and experiences of eating disorder recovery. She has an MSc in Family Relations and Human Development and a BA in Sociology. In her Masters research, she used qualitative and arts-based approaches (digital storytelling) to explore the experiences of young women in recovery from eating disorders. Andrea has recovered from EDNOS. She can be reached at andrea[at]scienceofeds[dot]org.

9 Comments

    • Thanks for reading! I’m hoping to post part 2 on Wednesday, so stay tuned 🙂

  1. Gee, of the 637 US programs (that were willing to respond), 514 offer no ED rotations ? That’s not encouraging at all. Whereas peer populations of young people often seem to have a pretty good idea of what EDs are about, with these sorts of numbers, it’s probably no surprise that sufferers who approach professionals often tell the sorts of stories they do. It’s good to hear that some academics are beginning to publish about this though – Good for you for helping to get the news out.

    • Yeah, super discouraging indeed. I was happy to find some articles on the topic- there were more than I thought there might be! I wish there weren’t the issue of non-response, because it would be great to get a true picture of what is/is not going on amongst all programs. But alas, a perfect world it is not…

  2. Great topic and very important – thank you. General practitioners are often the first contact for someone with an ED, so it’s always really bothered me that not many seem to know anything about them. Another common first-contact place seems to be Emergency – and there, not many seem to know much about ED either. The treatment, understanding, and attitude that someone encounters at their first contact can have such lasting repercussions for the rest of their treatment – it colours how they see professionals (them against me? Or them allied with me?), determines whether they are willing to seek help again in the future, can add to the shame or reduce it, can increase hope, or reduce it etc. So it is SO vital that they have an understanding, caring reception at their first contact. It also can make the difference in how long they suffer – if the first time they ask for help they get that help, it might cut years of the time they have to fight it for. A common thing I’ve noticed is that it seems to take several attempts to ask for help before anyone will take someone seriously, and then often it is too little too late.

    In my state in Australia there is ONE hospital offering an ED program, with just four beds on a general psych ward. That definitely gives very little chance of rotations in ED care. It also means the patients feel like guinea pigs – the registrar most often has never had anything to do with ED in their lives, and suddenly they are thrown into heading the ED team (with only the consultant over them in seniority) for 6 months – literally learning on the job. Most of them do a good job, but I can’t help thinking they need a lot more preparation for EDs before being thrown in the deep end. That’s psych registrars, too. Medical registrars, the chances and then contact are even lower – if they get a 6 month rotation on the psych ward that the ED unit is on, it’s for the entire ward so relatively little of their time is spent with the ED team and ED patients.

    It really isn’t good enough.

    • Thanks Fiona. Yeah, the ER is another place where these encounters often happen- from what I’ve seen in the literature so far there really isn’t much in the way of training for ER docs. I’ve seen other studies touch on ER doctors (I wrote about one when I wrote about the SCOFF screening tool) but from this it seems like if there is anything it is in paediatrics and psychiatry and even then. I definitely agree that this situation can seriously impact people’s willingness to reach out again, and can extend length of suffering (or make prognosis worse by having behaviours further entrenched by the time the person does get help- if they get help). Abysmal state of affairs that people practically have to beg for help; that doesn’t do much for feelings of being “legitimately sick enough” to get support and treatment! So scary about the state of affairs in Australia; I haven’t found any articles from Australia but I was kind of surprised I didn’t because there is some good ED research that goes on there… hm. Yes, the training really isn’t enough.

  3. Thank you so much for taking this issue on. As someone who taught high school in the recent past my eyes have been opened to how necessary it is to ensure all non-medical professionals on the front lines of interacting with youth and young adults must know the warning signs of eating disorders.

    You may have inspired me to try to find out how the ER doctor who literally shook me by the shoulders (to ensure I understood the severity of the situation) in the hallway outside the room where my 17-year old daughter was having her EKG after collapsing twice from orthostatic hypotension knew so much.

    I can’t even on the number of hours for psychiatry rotations. It defies all reason.

  4. Great article! I do not understand why family or general care doctors do not have more training with eating disorders. I remember my mom taking me to the hospital when I was a sophomore in high school because I was throwing up and she didn’t know why. Of course, I was ashamed and convinced my mom that it wasn’t me. I remember the doctor doing a check up and casually asking me if it was because I wanted to lose weight. I said “no” and that was that. No speaking to me one on one, or talking further to my mother (who also probably should have known). Perhaps if she had prodded me a bit further on the subject, I wouldn’t still be dealing with it almost 10 years later..

  5. This is so depressing. I’ve been dealing with an ED for over 30 years and I won’t go into the number of times doctors have told me I’m fine simply because I weigh more than 90 lbs. I’ve just given up now. I’m hoping this kind of article will shake someone by the shoulders and prepare medical professionals for the hard work ahead regarding this field of psychiatry. Please don’t stop writing.

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