It is challenging for me to rein myself in when I start ranting about the poor state of affairs of eating disorder training for medical professionals. However, I reconcile my critical ranting with a paradoxical penchant for optimism. I figured, in my searching, that there must be something out there that gives us more to work with. Is there a functional model of providing training for medical professionals? At the very least, are the opportunities that do exist doing a good job at equipping healthcare providers with the skills they need to begin to navigate the complexity of eating disorders?
Building on part one, in which I highlighted 2 studies offering some challenging knowledge around how little is on offer within medical training environments, I will focus here on 2 studies about the outcomes of training. The first, a UK study, explores whether medical professionals are trained in eating disorders and how well this training equips them to handle eating disorders in their various clinical fields. The second, from Canada, looks specifically at psychiatrists, who we might think would be the best prepared to handle eating disorders, and whether they are satisfied with their training.
What Counts as Good Training? A UK-based Study on Training Quality
Evidently, the presence of training rotations and/or more traditional teaching on how to treat eating disorders offers few guarantees about how good that training is. Following the implementation of the NICE (2004) guidelines for eating disorder treatment and management, Jones & Larner (2004) report on a project aiming to develop eating disorder services. They suggest that guidelines like the NICE offer specific principles for implementing effective treatment for eating disorders, However, Jones & Larner wrote their article 10-11 years prior to the studies I looked at in the first part of this series. So, I have to wonder, why have these guidelines not been taken up and used to inform training for medical professionals?
Jones & Larner surveyed 47 clinicians with an interest or specialty in treating eating disorders. Unlike participants in the first 2 studies I looked at, this is a group that they already had an interest or skills in this field. The researchers asked questions around whether these clinicians felt able to manage work with eating disorder patients/clients. Those surveyed were an interdisciplinary group, including nurses (adult, pediatric, school, etc.), counselors, psychologists, dietitians, social workers and psychiatrists.
This study goes into more depth around the specific types of therapies/treatments available to those with eating disorders and how well prepared clinicians working with eating disorder clients feel to navigate these. While it gives us more insight into whether clinicians feel their training has prepared them to handle the complexity of eating disorders, the survey did not include information about how the training was delivered and how well this matches the therapy/treatment designer’s intent in creating the therapy/treatment.
Somewhat distressingly, from the results of the survey it does not seem that healthcare practitioners feel better equipped to treat eating disorders following training. For example:
- 23 professionals were trained in cognitive-behavioural therapy (CBT), but only 13 of these said they felt that they were able to apply these skills
- Further, only one of the 23 rated that they would be able to train others in CBT with their level of training
This returns us to the question of where building the next set of eating disorder experts comes in. As I mentioned in the first post in the series, it is all well and good to rely on the expertise of those who know a lot about treating eating disorders, but it is important that this does not become an excuse to offer no training or unsatisfactory training to those coming up in the field. It becomes a bit of a self-perpetuating cycle in that there are not enough experts to train a new group of experts, thus creating even fewer opportunities for training in the future as the pool of experts shrinks. The experts may also become dispersed geographically, leading to gaping holes in the training in and provision of services for those with eating disorders.
There were also questions in the survey that spoke more generally to the experience of working with people with eating disorders. The authors say that the results here were promising, but I’m unconvinced; for instance, less than half of respondents reported being trained in:
- Care planning
- Nutrition and dietetics
- Effects of starvation
- Food avoidance behaviours
- Body image distortion
- Individual work
- Group work
- Patients, carers, family work
Further, very few of the respondents desired or received clinical supervision from supervisors specifically dealing with eating disorders. Of course, we should be cautious around generalizing these findings too far and wide, given that only 47 medical professionals responded. Nonetheless, the results indicate some preliminary perspectives on the inadequacies of the current state of affairs and the authors suggest ways of moving forward, including:
- Harnessing the power of online learning
- Building better group training systems, e.g., journal clubs, supervision networks, consultation and case presentation
- Collaborating across networks of excellence to facilitate ongoing training opportunities
Sadly, if we base our analysis on the studies I presented in the previous post, there appears to have been little movement in enhancing training, despite the fact that this article reads as a call for action. The authors place a particular emphasis on building on what knowledge does exist in order to create networks and better supervision opportunities, rather than reinventing the wheel. Something else that I liked is that the authors also note the importance of understanding and valuing patient and family lived experience in training:
“We must adopt and develop research methodology from relevant paradigms in order for [patients and carers] to research with us, rather than be researched by us.” (p. 22)
Increasing Training Opportunities? Canadian Psychiatry Training
So far, I’ve provided a very general overview of the state of training in the medical profession from an interdisciplinary/inter-professional standpoint. But what about psychiatry in particular? Is there anything going on in the psychiatric field that could scaffold training elsewhere? Moreover, since we might presume that psychiatrists would often be in charge of treating patients with eating disorders, how are they being trained, and how well do they feel that this training sets them up for the task at hand?
Some evidence from Canada points to an acknowledgment of and attempt to rectify the training gap practices related to eating disorders, at least in the psychiatry field. Williams & Leichner (2006) explored psychiatry resident training from 1990-2004 to survey the state of eating disorder training in Canadian psychiatry. They surveyed 180 psychiatry residents at 16 training centers in 1990 and compared this data with responses to an expanded version of this survey administered to 225 psychiatry residents in 2004 to see whether things had changed in the intervening years.
While the article provides a focus on attitudes toward eating disorders and more, I actually found the data on training to be striking in light of the above 3 studies. For example:
- In 1990, 50.8% of respondents reported having received training in eating disorders during their undergraduate medical training, whereas in 2004 only 44.2% reported the same
- Meanwhile, more residents reported having seen patients with eating disorders in 2004 (57.3% vs. 41.7% in 1990)
- More encouragingly, training on eating disorders in residency programs had increased from 79.4% in 1990 to 88.5% in 2004
- Still, very few respondents in either sample felt that their training laid enough of a foundation for them to move forward into practice with those with eating disorders: 19.1% in 1990 and 23.8% in 2004
- Even fewer reported satisfaction with training through clinical experiences with patients with eating disorders: 9% in 1990 and 6.3% in 2004
That only 6.3% of residents were very satisfied with clinical experiences with eating disorders is incredible to me. Participants in both articles were much more confident in their knowledge about eating disorders; it would appear that the gaps were primarily around their ability to work with those with eating disorders. And fair enough: I know quite a bit about eating disorders, but as a researcher, I am not at all prepared to work clinically with those with eating disorders. This is an issue that goes back to what we know about learning more generally and how to translate learning into practice: simply knowing something does not mean that you are equipped to practically manage demands and complexity. Knowledge is not behaviour.
So what did the respondents suggest might make their training experiences more comprehensive? Perhaps unsurprisingly (but note that these statements were only endorsed by about 3-23% of respondents, so take them with a grain of salt), residents desired:
- Hands on clinical experiences
- Mandatory rotations in eating disorders
- More classical instruction on eating disorders (e.g. lecture style)
- More information about/exposure to therapies and treatment approaches for eating disorders
- More practical/applied/case-based courses
- More supervisors or more intensive supervision
A final important note about the training environment reported by residents in this study is that 28% of respondents in 2004 reported having heard negative statements about eating disorders in their training environment. For example, residents reported having heard ED patients being described as “difficult, frustrating and/or exhausting to work with” or judgment toward ED patients as being at fault for the illness, controlling, or manipulative. If this is a sentiment pervading the training environment, is it any wonder that training opportunities and commitment to building the next generation of eating disorder professionals is lagging?
In the next post in this series I will explore how eating disorder clinicians may experience burnout as a part of their job, digging into the problem from another angle; the struggle of working in a field with high demand and little support. That post will take a birds-eye view of the situation, placing all of this into the socio-political environments in which training takes place. I’m hopeful that this series in general accomplishes a goal of alerting us to the lacking training environment, but also avoiding placing blame on clinicians and future clinicians, who may well be seeking out but not finding training. And while training opportunities do exist here and there, without the political will to support and fund training, we are left wanting.
Jones, J. & Larner, M. (2004). An audit of training, competence and confidence among clinicians working in eating disorder services. Mental Health Practice. 8(3), 18-22. http://dx.doi.org/10.7748/mhp2004.11.8.3.18.c1833
Williams, M. & Leichter, P. (2006). More training needed in eating disorders: A time cohort comparison study of Canadian psychiatry residents
Eating Disorders, 14(4), 323–334. DOI: 10.1080/10640260600796267