Eating disorders on the wards

Anna Crane and colleagues guide you through two common yet often misconstrued medical conditions in adolescents

Picture this. Rebecca, a final year medical student, approaches an elderly patient on her ward. She has been asked to replace a cannula. They chat while Rebecca touches the woman's arm, deciding on a vein. To the woman, Rebecca's hands feel cold and bony. She looks at them. They are blue. Their faces are close. The woman sees Rebecca's pallid skin, her dark circled eyes, and what appears to be muscle fibres stretched across her hollow cheeks. She compares their arms as the cannula slips in-prominent veins; peeling skin; and fine, long hair. Rebecca finishes, thanks her, and walks away. The woman stares at her profile-her width, her lack of curves and shape-protruding bones, visible ribs, and a head that seems too large for its body.
 

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Shocked? Well, how about this. Zoe drops into Tesco on her way home from the hospital. On returning to her flat she's ravenous. She eats, hurriedly shoving anything into her mouth, unable to stop. Urgency is followed by pain, self disgust, panic, and revulsion. She runs to the toilet, pushing her fingers down her throat. "Is it all out?" She's terrified: "Please, God, let it all be out."

What have just been described are the unmistakeable conditions of anorexia nervosa, where an individual is malnourished and often visibly grossly underweight, and bulimia nervosa, in which someone remains discrete and hidden beneath their normal body weight. But what of someone who binges, fasts, or has strange eating patterns and habits and seriously misjudges their body size and figure? Sound all too common? Well, they most likely have an EDNOS (an eating disorder not otherwise specified), not really fitting the diagnosis of either anorexia or bulimia. In a previous studentBMJ article, Rhona MacDonald made the valid point that perhaps a person should not have to fit any of these diagnostic categories to be considered to have "disordered eating.^w1 Seen or unseen, eating disorders, varying in severity, are all around us.

In the April 2006 edition of the studentBMJ, an anonymous student described her relationship with Ed, the eating disorder that forced her to take time out from medical school.^w2 A rapid response to this article highlighted the fact that her experience is far from unique: 19% of female medical students have had disordered eating.^w3 Comparable figures have been recorded for the prevalence of eating disorders among students of other subjects, including the arts,^w4 but there is a key difference: medical students tend to present later because they fear that they will face discrimination in their chosen profession. This subject is particularly topical at present because in the United Kingdom, the General Medical Council is considering extending its fitness to practice regulations, aimed at qualified doctors, to additionally cover medical students.^w5 Two important questions arise from this discussion: "Does having an eating disorder make you ‘unfit to practice'?" and "How best can medical schools support the huge number of their students who are suffering?"

Relevant guidelines?

Students' fears that they will not be allowed to continue their studies while affected by an eating disorder may stem from the continued stigma surrounding the conditions.^w6 In health care, however, a personal experience of a mental health problem is generally viewed in a positive light-promoting diversity, adding experience, and bringing knowledge to the profession.^w7 It is questionable whether the understanding and empathy given by an affected or recovered health professional to a fellow patient can be bettered.

While considering this, remember, that according to the GMC's Tomorrow's Doctors guidelines, it is a doctor's duty and responsibility to ensure that his or her own health never puts a patient at risk and, following from this, if a student is thought to be a risk to patients then "they are not allowed to graduate with a medical degree.^w8This suggests that having a mental health problem in itself does not make a student unfit to practise: the key factor is whether the problem poses a risk to patients.

Risks to patients?

At a low weight, concentration span is reduced and findings show that people with anorexia do poorly across a range of neuropsychological tests, including decision making.^{w9 w10} Bulimic patients often report overwhelming feelings of self hatred, self disgust, shame, and guilt along with constant thoughts about body weight and shape.^w11 Malnourished anorexic patients often think of food and eating to the exclusion of everything else.^w12 Given these circumstances, how does a health professional work safely and effectively with this kind of thought bombardment? Moreover, in combination with a poor physical state of health and a coexisting affective disorder, common in people with eating disorders,^w13 the situation looks unfavourable.

A doctor whose concentration is poor and who is unable to think clearly about clinical questions definitely poses a risk to patients. A medical student, who cannot be responsible for prescribing or for making decisions about treatment and who carries out practical procedures only under supervision has less opportunity to cause harm. History taking may be disjointed and they may be unable to present in a cogent manner: in this sense they may risk harming themselves more than their patients.

Conversely, though, people with eating disorders have much to offer. The Eating Disorders Association emphasises that sufferers bring the strengths of productivity, diligence, and loyalty to a workplace.^w14 Indeed, the very traits that put people at risk of developing an eating disorder-attention to detail, ability to focus, fear of making mistakes, and a tendency to please others ^w15-are particularly valued, and perhaps essential in health professionals.

Personal risks

Medical students with eating disorders are at risk of delaying seeking help, which may affect their performance. Studying medicine can also be a stressful experience: medical students report higher levels of psychological symptoms than the general population and these symptoms increase in successive years of the course.^w16 Perfectionism and financial or academic pressures are known to precipitate eating disorders and may also perpetuate a student's illness.^w17 It is easy to rationalise rigid revision routines and the prioritisation of study over eating when faced with imminent exams.

The haphazard structure of many clinical placements may also contribute to students' deterioration. Few timetables have designated meal breaks and teaching is often delivered at lunch time, which makes it easy for students to avoid eating. The constant demand to adapt to and deal with change undoubtedly adds further pressure. A student may face a new hospital, a new firm, and a new specialty on a regular basis. Placements are also physically demanding: a student may have to undertake an arduous journey to get to the hospital, endure a long ward round, clerk patients, stand for hours in theatre, and attend teaching before travelling all the way home again to begin the cycle anew the next morning. To do all this requires energy, which will be in short supply if a student has a poor food intake. The risk of developing physical complications is therefore high.

Aside from fearing the consequences of disclosing their problem, students may choose not to present for treatment on the basis that they simply do not have time: even regular outpatient appointments may appear to be incompatible with the demands of their course. Often the physical, psychological and social costs of living with an eating disorder seem more bearable than those of dropping behind. Unfortunately, the capacity to recognise that behaviour is a problem decreases with weight, meaning that someone with disordered eating is likely to resist treatment until enforced "time out" is necessary.

The role of medical schools

Medical schools have a duty to ensure that their students are fit to practise after graduation. They also have a duty of pastoral care towards their students during their course. There is a lack of consensus regarding the best means of assessing fitness to practise in the context of an eating disorder: any judgment based on body mass index alone seems unsatisfactory given the high prevalence of comorbid disease and the occurrence of bulimia in people of normal weight. What is evident is that every student who struggles with an eating disorder is "fit to be supported," and guidelines have been produced which inform universities of the best means of doing this ^w16-w18:

Medical schools are responsible for teaching students to look after their own mental health: they should alert students to the known risk of developing an eating disorder and encourage them to seek help early.

• Medical schools must have official pathways for seeking help with mental health issues including eating disorders-for example, through individual academic advisers, a specified student support officer, or a walk-in clinic. These points of contact should be widely publicised and easily accessible.
• Staff involved in these pathways should receive training so that they can tackle students' fears and refer appropriately.
• Medical schools should be aware that some students will be reluctant to seek help through official channels and should promote alternative sources of support including voluntary organisations and services led by students. New examples include ACCESs (a web based Cognitive Behavioural Therapy treatment programme for sufferers of bulimia at Kings College London and St George's Medical school^w19) and SWEDA (Somerset and Wessex Eating Disorders Association led support groups at Bristol and Exeter universities^w20).
• A central service offering students information on all options for support and treatment should be available.
• Once a student is known to have an eating disorder, staff should work with them to establish the best means of balancing their health needs with their education: this may necessitate a case conference involving external services.
• Regular reviews should be organised so that the student feels supported and so that specific difficulties can be dealt with as quickly as possible.

Medical students with eating disorders have intense physical and emotional pain, often compounded by shame and a fear that they will be considered unfit to practise once their secret is revealed. Eating disorders can impair clinical performance but at undergraduate level pose a greater risk to the student than to patients. However, if neglected an eating disorder will undoubtedly render a student unfit. Ultimately, their career is in jeopardy but, more importantly, so is their life. Early treatment is a crucial step to making a full recovery. For early treatment to occur, an eating disorder needs to be recognised. The last people to acknowledge they have a problem will be the students themselves. Their illness swears them to silence.

Medical schools must have policies for supporting affected students to optimise their chance of recovery. Recovery from an eating disorder is possible and the qualities that characterise medics with eating disorders make them a cohort of tomorrow's doctors that the profession cannot afford to lose.
 

CAROL@MIKE/WEKNEK/PHOTOTAKE INC/ALAMY
Through a glass, darkly

Anna Crane, final year medical student, Guy's, King's, and St Thomas' Medical School, London
Email: anna.crane@kcl.ac.uk
Janet, Treasure director, Eating Disorders Unit, South London and the Maudsley NHS Trust
Sharon McConville, final year medical student, Queen's University, Belfast

Competing interests: None declared.

studentBMJ 2007;15:45-88 February ISSN 0966-6494

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