Ten years ago, Clare Gerada, FRCGP, an advocate for physician well-being and today President of the UK's Royal College of General Practitioners, made a prediction to the audience at the International Conference on Physician Health.
"We have seen a massive increase in eating disorders [among doctors]," she said. "I'm not sure anybody is quite aware of the tsunami of eating disorders," she believed would soon strike predominantly female physicians.
That was 2014. Did the tsunami hit?
Quite possibly. Data are limited on the prevalence of eating disorders (EDs) among healthcare workers, but studies do exist. A 2019 global review and meta-analysis determined "the summary prevalence of eating disorder (ED) risk among medical students was 10.4%."
A 2022 update of that review boosted the estimate to 17.35%.
Tsunami or not, that's nearly double the 9% rate within the US general public (from a 2020 report from STRIPED and the Academy of Eating Disorders). And while the following stat isn't an indicator of EDs per se, 19% of doctors admit to unhealthy eating habits, according to a recent Medscape Medical News physician survey.
To her credit, Gerada, awarded a damehood in 2020, was in a position to know what was coming. Her statement was informed by research showing an increasing number of young doctors seeking treatment for mental health issues, including EDs, through the NHS Practitioner Health program, a mental health service she established in 2008.
So…what puts doctors at such a high risk for EDs?
Be Careful of 'Overlap Traits'
As with many mental health issues, EDs have no single cause. Researchers believe they stem from a complex interaction of genetic, biological, behavioral, psychological, and social factors. But the medical field should take note: Some personality traits commonly associated with EDs are often shared by successful physicians.
"I think some of the overlap traits would be being highly driven, goal-oriented and self-critical," said Lesley Williams, MD, a family medicine physician at the Mayo Clinic in Phoenix, Arizona. "A lot of those traits can make you a very successful physician and physician-in-training but could also potentially spill over into body image and rigidity around food."
Of course, we want physicians to strive for excellence, and the majority of diligent, driven doctors will not develop an ED.
But when pushed too far, those admirable qualities can easily become perfectionism — which has long been recognized as a risk factor for EDs, an association supported by decades of research.
Medical School: Where EDs Begin and Little Education About Them Happens
"I think medicine in general attracts people that often share similar characteristics to those who struggle with EDs — high-achieving, hardworking perfectionists who put a lot of pressure on themselves," said Elizabeth McNaught, MD, a general practitioner and medical director at Family Mental Wealth.
Diagnosed with an ED at 14, McNaught has experienced this firsthand and shared her story in a 2020 memoir, Life Hurts: A Doctor's Personal Journey Through Anorexia.
Competitive, high-stress environments can also be a trigger, McNaught explained. "The pressure of medical school," for example, "can perpetuate an eating disorder if that's something that you're struggling with," she said.
Pressure to perform may not be the only problem. Medical students are taught to view weight as a key indicator of health. Multiple studies suggested that not only does weight stigma exist in healthcare but also it has increased over time and negatively affects patients' psychological well-being and physical health.
There is far less public discourse about how weight stigma can be harmful to medical students and physicians themselves. Williams believed the weight-centric paradigm was key.
"For so long, we believed that health presents itself within these confines on a BMI chart and anything outside of that is unhealthy and must be fixed," she said. "I can say from having gone through medical education, having that continual messaging does make someone feel that if I myself am not within those confines, then I need to do something to fix that immediately if I'm going to continue to care for patients."
In general, Williams and McNaught agreed that medical training around EDs is lacking, producing doctors who are ill-equipped to diagnose, treat, or even discuss them with patients. Williams recalled only one lecture on the topic in med school.
"And yet, anorexia carries the second highest death rate of all mental illnesses after opioid-use disorders," she said, "so it's astonishing that that just wasn't included."
MDs Hiding Mental Health Issues
Clara Anderson, MD, (a pseudonym) emphatically stated she would never tell anyone at the hospital where she works in the emergency department that she has an ED.
"There is still a lot of misunderstanding about mental health, and I never want people to doubt my ability to care for people," Anderson said. "There's so much stigma around eating disorders, and I also feel like once it's out there, I can't take it back, and I don't want to feel like people are watching me."
Melissa Klein, PhD, a clinical psychologist specializing in EDs, has more than 25 years of experience working the inpatient ED unit at New York Presbyterian. Having treated medical professionals, Klein said they have legitimate concerns about revealing their struggles.
"Sometimes, they do get reported to higher ups — the boards," Klein said, "and they're told that they have to get help in order for them to continue to work in their profession. I think people might be scared to ask for help because of that reason."
Doctors Often Ignore EDs or Teach 'Bad Habits'
Anderson firmly believed that if her early treatment from doctors had been better, she might not be struggling so much today.
The first time Anderson's mother brought up her daughter's sudden weight loss at 14, their family doctor conferred with a chart and said there was no reason to worry; Anderson's weight was "normal." "I was eating like 500 calories a day and swimming for 3 hours, and [by saying that], they assured me I was fine," she recalls.
At 15, when Anderson went in for an initial assessment for an ED, she thought she'd be connected with a nutritionist and sent home. "I didn't have a lot of classic thoughts of wanting to be thin or wanting to lose weight," she said.
Instead, Anderson was sent to inpatient care, which she credits with escalating her ED. "I picked up on a lot of really bad habits when I went there — I sort of learned how to have an eating disorder," she said. "When I left, it was very different than when I went in, which is kind of sad."
Throughout high school, Anderson went in and out of so many hospitals and treatment programs that she's lost track of them. Then, in 2008, she left formal treatment altogether. "I had been really angry with the treatment programs for trying to fit me into their box with a rigid schedule of inpatient and outpatient care," she recalled. "I didn't want to live in that world anymore."
After working with a new psychiatrist, Anderson's situation improved until a particularly stressful second year of residency. "That's when I just tanked," she said. "Residency, and especially being on my own and with COVID, things have not been great for me."
Anderson now sees an eating disorder specialist, but she pays for this out-of-pocket. "I have terrible insurance," she said with a laugh, aware of that irony.
If You Are Struggling, Don't Be Ashamed
Some physicians who've experienced EDs firsthand are working to improve training on diagnosing and treating the conditions. McNaught has developed and launched a new eLearning program for healthcare workers on how to recognize the early signs and symptoms of an ED and provide support.
"It's not only so they can recognize it in their patients but also if colleagues and family and friends are struggling," she said.
In 2021, the American Psychiatric Association (APA) approved the APA Practice Guideline for the Treatment of Patients With Eating Disorders, which aims to improve patient care and treatment outcomes.
But Klein is concerned that increased stress since the COVID-19 pandemic may be putting healthcare workers at even greater risk.
"When people are under stress or when they feel like there are things in their life that maybe they can't control, sometimes turning to an eating disorder is a way to cope," she said, "In that sense, the stress on medical professionals is something that could lead to eating disorder behaviors."
Klein's message to healthcare workers: Don't be ashamed. She described an ED as "a monster that takes over your brain. Once it starts, it's very hard to turn it around on your own. So, I hope anyone who is suffering, in whatever field they're in, that they are able to ask for help."
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