The prejudice against people with eating disorders extends to clinicians, who are as misinformed as the public. The basic medical and psychiatric understanding of anorexia and bulimia are not part of medical training. Primary doctors have sporadic exposure to patients suffering with these illnesses but no guidance about how to manage them. Even psychiatrists in training can graduate with no more than a cursory knowledge of the diagnostic criteria for eating disorders. If anorexia is the most fatal of all psychiatric diseases, then medical education is missing the boat.
The life of a recovering patient remains isolated, lonely and gravely misunderstood. While family and friends struggle to comprehend how anyone could have trouble eating, something so basic to human existence, the sick are typically silent. But what happens when physicians approach anorexia and bulimia with similar ignorance? The risks are much more consequential.
Too many of my patients have had difficult experiences with doctors. For some, the scars are emotional and that makes seeking medical help in the future a scary proposition. Arrogant doctors typically think one of two things: that they will save the patient or that the patient needs to just buck up and eat. Either erodes a patient's trust in medicine and prompts the person to go it alone. Many others are physically harmed by doctors unaware of the precarious balance the human body reaches to survive an eating disorder. A person with bulimia can adapt to usually lethal blood potassium levels and frightened doctors may dangerously raise the level too fast. Doctors also don't know that overfeeding a very underweight person with anorexia is potentially lethal and will do so anyway. The bold medical interventions aren't just pointless, they can kill.
This leaves treatment in a difficult spot. On any typical day, a doctor relies on the nearest hospital emergency room. I suspect everyone has heard a doctor's voicemail message stating the obvious, "If this is an emergency, please hang up and call 911 or go to your local emergency room." In this message, a doctor is sure to impart a clear directive to a scared and confused patient. In addition, the doctor implies confidence that the ER will address the problem adequately and quickly.
I don't say that in my voicemail message for a reason. It's not because my patients don't often need an emergency room. They do. It's that emergency room doctors do not know how to treat people with severe eating disorders. The sight of a malnourished patient tends to elicit horror and hasty action. The shockingly abnormal lab values in a very sick patient with bulimia leads to the same reaction. An ER doc is supposed to have seen it all. They are supposed to be able to handle any form of crisis and use their knowledge to save a patient. The misinformed, judgmental response of many of these doctors makes an ER one of the least safe places for anybody with an eating disorder. When I do send my patient to a hospital, I am sure to be on standby to protect them as much as anything. These patients often need immediate medical care I can't provide, but when in an ER they practically need an escort to be sure they survive.
Sadly, much of the problem lies in the prejudice. Doctors absorb most of their information about eating disorders from the press and entertainment industry. Convinced of their suspect views about food and weight in general, doctors typically know even less about eating disorders but have no trouble expressing faulty opinions, even when on call. And that precipitates poor, dangerous treatment decisions. Most doctors consult textbooks and supervisors when faced with an unfamiliar situation, but who can help treat anorexia and bulimia? There is ever-growing public attention on food, weight and eating disorders; the problem is ubiquitous and garners significant attention. Just a little time engaging with the main stream media attests to the topic's popularity. It's about time the medical community pays attention and realizes our job isn't to form an opinion but to learn how to keep these patients stable and safe.
Thank you Dr Lissak for this wonderful post. Thank you for your whole blog actually- I found it awhile back, and I check in regularly. I am struck by how much thought and care you devote to these blog posts. I hope you write a book someday- the psychiatric community would really benefit from your contribution. It is my impression that psychiatrists in general view pts with eating disorders with the same apprehension and/or disgust as they do pts with personality disorders. Many psychiatrists are reluctant to take on patients with these diseases, I think, because ed patients seem like they don't want to get better. Actually, they (ok, WE) do want to get better, desperately, because we are not stupid people and we realize all the dangers involved in ed behaviors, and we are not suicidal (most days of the week), but conventional treatment just doesn't seem to work. I am embarrassed to say how long I had been in treatment, how long I stayed with the same psychiatrist who said really insenstive things sometimes. I tried other doctors too, but I just kind of gave up hope after awhile. But you give me hope- hope that there are more doctors out there like you. So, thank you.
ReplyDeleteWhat about the 3rd kind of doctor? The doctor that isn't treating the eating disorder but knows it exists. The one who is so ignorant and unaware of eating disorders he/she tells someone at 88 lbs they look great. Or the one who tells someone who has regained weight they look healthy so they must be better... completely missing the point all together. Thank you for pointing out the complete lack of understanding about eds in the medical industry and thank you for being one of the few who does not fall into that category!
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