I was going to blog more about mortality rates in eating disorder patients, but recent ED-related deaths have left a bitter taste in my mouth (huge understatement). So, I’ve decided instead to write about a paper requested by the founder of The Joy Project on clinician reactions to patients with eating disorders by Thomspon-Brenner and colleagues that came out this year.

If you have an eating disorder or are close to someone with an eating disorder, you’ve likely heard many stories about dismissive or down-right negative and harmful attitudes that clinicians often have toward patients with EDs.

I’ve experienced it myself: I had to find another doctor to refer me to an outpatient clinic, because the first one didn’t – he didn’t think I needed help (probably because I was very aware that things were not heading in the right direction even before I was at a low weight). Needless to say, my new doctor refereed me ASAP, thankfully, and by the time I got diagnosed, I more than fit the diagnostic criteria. So there’s that: a clinician standing in the way of early detection and treatment.

These attitudes hurt patients, a lot.

The goal of Thomspon-Brenner et al was to review published studies on clinician reactions to patients with EDs. They found 20 such studies (from 1984-2010). The summary of their analysis revealed:

Clinician negative reactions in regard to patients with eating disorders typically reflected frustration, hopelessness, lack of competence, and worry. Inexperienced clinicians appeared to hold more negative attitudes toward patients with eating disorders than toward other patient groups, but experienced psychotherapists did not experience strong negative reactions to patients with eating disorders. Medical practitioners consistently reported strong feelings of lack of competence in treating eating disorders. Negative reactions to patients with eating disorders were associated with patients’ lack of improvement and personality pathology and with clinicians’ stigmatizing beliefs, inexperience, and gender.

Here’s the summary of the main findings:

MAIN FINDINGS

Highlights of studies of inexperienced clinicians and trainees revealed:

first year residents (including psychiatry residents) had more negative attitudes toward patients with anorexia nervosa than obesity or diabetes

medical and nursing students considered patients with eating disorders to be significantly more responsible for their illness than schizophrenic patients

31% of therapists from a variety of disciplines (psychiatry, psychology) preferred NOT to treat eating disorder patients

most common feelings toward ED patients included frustration and anger

nurses working WITH ED patients reported increasingly MORE negative impressions of ED patients as their interactions with them continued

Specialists and highly experienced psychotherapists had overall better responses:

clinicians in this category did not experience the same degree of negative feelings toward ED patients

high alliance between physician and patient was reported in highly trained psychotherapists

the most common negative reactions were: frustration, lack of competence, worry and boredom.

difficulties that experienced clinicians report when working with ED patients: lack of readiness to change, resistance, nature of illness, negative affect

General surveys of medical professionals that do not work specifically with ED patients:

clinicians often felt lack of confidence or competence in treating ED patients

a 1990 survey found that 54% of physicians felt incompetent in treating patients with eating disorders (second most common area of perceived lack of competence).

found that 54% of physicians felt incompetent in treating patients with eating disorders (second most common area of perceived lack of competence). many desired increased training in EDs

Why do clinicians react the way they do?

Thompson-Brenner attempted to identify predictors that account for the negative reactions.

Clinicians’ reactions to patients with eating disorders appeared to vary according to the perception of the patient’s response to treatment, the degree to which clinicians endorsed stigmatizing beliefs about the patient’s responsibility for his or her illness, the amount of experience they had had generally and specifically with eating disorders, their gender [male clinicians held more negative attitudes than female clinicians] and discipline, and the patient’s personality pathology [reactions were worse to patients with Axis II personality disorders].

Importantly (and this is true for everything, not just mental health):

Negative reactions to patients with these disorders in the form of stigma may contribute to the reluctance of patients to seek or continue treatment. Decreasing providers’ stigmatizing beliefs and behaviors would likely result in better access to care and more successful referrals and outcomes for patients with eating disorders….. clinician attitudes, knowledge, and stigma likely adversely affect both the quality and the availability of services for patients with eating disorders.

In reading this review, keep in mind: the studies were collected over 3 decades of research and a lot (arguably) has changed in our collective understanding of the biological nature of eating disorders and how to treat them. How much of this is still true today? I don’t know – more research is definitely necessary.

What about depressing findings such as this:

Data indicating that clinicians commonly hold blaming or stigmatizing attitudes toward patients with eating disorders were collected across a wide range of years, locations, and professional disciplines. When asked in 1992 to consider the origins of psychiatric illness among patients with anorexia nervosa, schizophrenia, and recurrent overdoses, medical professionals considered patients with the eating disorder significantly more responsible for their illness than patients with schizophrenia and about as responsible as patients with recurrent overdoses. Furthermore, the same study found that these attitudes did not change over the course of training.

What can be done about this?

I think it is abundantly clear that healthcare professionals – nurses, doctors, dentists, therapists, nutritionists, etc.. – would benefit from improved training on issues in mental health, particularly eating disorders. The first few years of training seem to me to be a critical time to really emphasize the importance of taking mental health concerns seriously. I think the best way to achieve this is by educating students on the etiology of mental disorders (as much as we know), on what treatments are available and how well they work, on why patients may behave the way they behave, and how to interact with patients in a way that validates their feelings and makes them an ally, not an enemy. Maybe brining in patients with eating disorders to share their stories (I’d definitely do that if I had an opportunity). Brain & Behaviour is a huge section of my University’s first-year medical school curriculum – yet, with the exception of a problem-based learning module, eating disorders were not covered (in the year my boyfriend was a first year medical student). It seems other mental health issues suffer the same trajectory. Why are rare neurological diseases covered but more prevalent mental disorders not?

In my view: this training needs to happen in the first 2 years of medical school. Not during residency. Why? Because much of what needs to be taught will impact the quality of clinicians’ interactions with patients – all patients. Why else? Because in the case of eating disorders, as I blogged earlier, they are mental disorders with physical consequences. From dental erosion, to numerous GI and cardiac problems, amenorrhea and possible infertility – it is likely that if you are in or plan to go into medicine, you’ll encounter patients with eating disorders (whether you know or not). It is important to be aware of that, be aware of your prejudices and preconceived notions: because the implications are huge.

Importantly, eating disorders are not the only problems that get ignored, dismissed or not taken seriously by clinicians – unfortunately. A 30 minute CBC radio podcast (by an ER physician that works in the same hospital where my lab is located, actually) had a very good show on this very topic (he didn’t cover ED’s): Diseases that get no respect. I highly recommend it – it includes perspectives from patients, clinicians and delves into some of the reasons for the problem.

Readers – share your experiences with clinicians (good or bad) and your thoughts on the matter: how would you go about improving the situation?

Edit: Accompanying news article on this paper from Psychiatry Online (with quotations from Thomspon-Brenner) can be found here.

Follow-up Post: When Clinicians Do More Harm Than Good – Part 2: This post looks at some negative consequences of treatment and asks the question, can treatment do more harm than good?

References

Thompson-Brenner, H., Satir, D., Franko, D., & Herzog, D. (2012). Clinician Reactions to Patients With Eating Disorders: A Review of the Literature Psychiatric Services, 63 (01), 73-78 DOI: 10.1176/appi.ps.201100050