by Vivian Lee, M.A., Medical Student at The University of Texas Medical Branch, and CEED Summer Research Fellow 2024
Earlier this year, I gave a workshop to a group of family medicine residents at a prominent medical school in Texas. As we reviewed common psychiatric diagnoses together, I presented the hypothetical case of a 16-year-old female presenting with subjective weight gain over the past 12 months. Her patient profile described comorbid mood and anxiety symptoms accompanied with psychosocial risk factors. A table of abnormal blood counts and metabolic panel values followed.
The residents eagerly piped up, naming several prominent disorders of concern: major depressive disorder, generalized anxiety disorder, adjustment disorder. Perhaps the weight gain was due to her depression? Perhaps diabetes, as it ran in her family? What if it was a rare pituitary tumor?
Not a single resident was able to look at the complete picture of this patient, including her lab results—hypokalemia, high CO2, elevated serum amylase—and correctly identify her diagnosis: bulimia nervosa.
Physicians are often the first healthcare professionals in a position to identify and intervene with eating disorders. Especially in states like Texas, where the wait-list for an outpatient psychiatrist can range between 1 to 6 months, primary care physicians are frequently the first and only line of defense as an eating disorder progresses. They end up juggling complex cases that equally span medical and psychiatric concerns, which they are typically not well-equipped to manage.
Presently, I am working with a research group at my home institution to research and quantify the amount (or lack thereof) of eating disorder training present at the medical school and residency levels of training. The results are sobering: In my medical school curriculum, I received minimal education in identifying and treating eating disorders: just a short 3000-word chapter that covered in whirlwind detail the DSM-5 diagnostic criteria and several common therapeutic interventions. Many schools, both within the US and internationally, have equally scant eating disorder education built into their curriculum, with most of the focus being placed on diagnostics instead of treatment.1,2
Psychiatry residency tracks rarely offer required experience with eating disorder patients, and of those that do offer electives, they are limited to short durations (e.g., 1-2 weeks). For our colleagues in internal medicine and family medicine, specific eating disorder training usually does not occur until the fellowship level, and typically only in adolescent medicine fellowships.3 A minuscule number of emergency medicine physicians (only 1.9% per a 2021 study)4 get any training on eating disorders, despite the fact that acute presentations of eating disorder symptomatology (such as bradycardia, severe dehydration, or ketoacidosis) often first present to the emergency department.
Although exposure to eating disorders may certainly occur throughout training, they are often incidental and it is highly likely that many cases remain undetected by trainee physicians. Once these physicians are practicing in the community, the vast majority (up to 78%)5 report low levels of confidence in treating patients with eating disorders, and equally low rates of screening and accurate diagnosis.6 Research has also quantitatively illustrated the substantial gaps in knowledge about eating disorders and the need for formal training.7,8
Not all is lost, however. Many organizations have recognized the education gap and are actively developing resources to address this, such as the National Center of Excellence for Eating Disorders, which provides webinars, toolkits, collections of peer-reviewed articles, and screener tools for primary care physicians. The Academy for Eating Disorders (AED) also maintains a vast library of resources for various healthcare professionals, including the well-known “purple book” (Eating Disorders: A Guide to Medical Care) published in 11 languages by AED’s Medical Care Standards Committee. Many of the currently available resources focus solely on practicing healthcare providers, and further rely on the providers to actively seek out these resources. There is certainly additional need for education that is embedded at the student and trainee level.
It is my hope that as I progress throughout my career as a physician in training, I will be able to give back by developing and nurturing these much-needed educational programs. Our eating disorder patients have nuanced stories and deserve high-quality, evidence-based, easily accessible care by well-trained physicians.
References:
1. Girz, L., Robinson, A. L., & 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. https://doi.org/10.1080/10640266.2014.915692
2. Ayton, A., & Ibrahim, A. (2018). Does UK medical education provide doctors with sufficient skills and knowledge to manage patients with eating disorders safely?. Postgraduate Medical Journal, 94(1113), 374–380. https://doi.org/10.1136/postgradmedj-2018-135658
3. Tse, A., Xavier, S., Trollope-Kumar, K., Agarwal, G., & Lokker, C. (2022). Challenges in eating disorder diagnosis and management among family physicians and trainees: a qualitative study. Journal of Eating Disorders, 10(1), 45. https://doi.org/10.1186/s40337-022-00570-5
4. Ma, C., Gonzales-Pacheco, D., Cerami, J., Coakley, K.E. (2021). Emergency medicine physicians’ knowledge and perceptions of training, education, and resources in eating disorders. Journal of Eating Disorders, 9(4). https://doi.org/10.1186/s40337-020-00355-8
5. Linville, D., Benton, A., O’Neil, M., & Sturm, K. (2010). Medical providers’ screening, training and intervention practices for eating disorders. Eating Disorders, 18(2), 110–131. https://doi.org/10.1080/10640260903585532
6. Ayton, A., & Ibrahim, A. (2018). Does UK medical education provide doctors with sufficient skills and knowledge to manage patients with eating disorders safely?. Postgraduate Medical Journal, 94(1113), 374–380. https://doi.org/10.1136/postgradmedj-2018-135658
7. Currin, L., Waller, G., & Schmidt, U. (2009). Primary care physicians’ knowledge of and attitudes toward the eating disorders: do they affect clinical actions?. The International journal of Eating Disorders, 42(5), 453–458. https://doi.org/10.1002/eat.20636
8. Anderson, K., Accurso, E. C., Kinasz, K. R., & Le Grange, D. (2017). Residents’ and Fellows’ Knowledge and Attitudes About Eating Disorders at an Academic Medical Center. Academic Psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry, 41(3), 381–384. https://doi.org/10.1007/s40596-016-0578-z
