Written by Jennifer L. Gaudiani, MD, CEDS and originally featured on the The Emily Program (formerly known as the Veritas Collaborative) blog.
If you or a loved one has an eating disorder, odds are that you have been failed by the outpatient medical system. That’s a big word — failed — and I don’t use it lightly.
Many of my patients tell me frankly that they don’t trust doctors, and they have good reasons. Office staff might make comments like, “Oh, you’re so thin! What willpower you must have,” dissolving a fragile intention to admit to an eating disorder and seek help. Some doctors can buy into the eating disorder’s logic and agree, “Yep, your heart rate must be 30 because you’re an athlete,” and the patient returns to their frantically worried therapist saying, “The doctor says I’m fine.” Patients are often given the message that they’re “difficult,” need to “just eat,” or feel shamed by an exasperated physician. Above all else, the average eight-minute appointment cannot possibly begin to serve the needs of a patient and family who need the opportunity to tell their whole story. Frequently, patients don’t even get time to reveal their eating disorder during an eight-minute visit. Small wonder those with eating disorders, and their families, have developed an aversion to doctors!
However, full disclosure, I’m a doctor. I’ve been taking care of patients with eating disorders for the last eight years. My goal in this blog is not to breathe fire on doctors, because for the most part, they mean well, and their faults with patients with eating disorders mostly stem from lack of knowledge about eating disorders (they get almost no training in medical school or residency), lack of time because of insurance pressures, and perhaps lack of personal passion for the field. In fact, many of the terrific physicians who are passionate about eating disorders have joined treatment programs, where they give remarkable care. This can leave families with fewer expert options in the outpatient setting, however. My goal here is to suggest to patients and their families what they might advocate for when they choose a medical doctor. Ultimately, the hope is that with physician support, patients’ needs are met in a way that allows them more smoothly to move toward recovery, and their outpatient clinical team’s needs are met by being assured that the client is being monitored medically, while therapy and nutritional rehabilitation continue.
Ideally, expertise in eating disorders would be added to the list, but I’m all too aware of how few internal medicine and family practice doctors have substantial eating disorder expertise. I believe physicians with these three traits, even in the absence of eating disorder expertise, can make a big difference. And you should ask around, get referrals, and demand a doctor who meets these criteria.
Connection is the first key trait. To treat someone with an eating disorder, a doctor must have a strong desire to connect personally with the patient and with their outpatient team. Connection means creating a protected, unrushed, and safe clinical environment in which patients and their families are warmly encouraged to tell their whole story. True connection means that the doctor will honor the patient’s values and goals as being the fundamental starting point for all discussions of recovery and wellness maintenance. That doesn’t mean, of course, that a fifteen-year-old can say, “My core value is thinness,” and it ends there. It means that over the course of meaningful listening—to the patient, their family, and their outpatient team—the doctor can reflect unique and personal beliefs in order to motivate the fight against the eating disorder voice. For instance, “I can tell you are struggling so much to make even incremental changes right now in your behaviors. I’m keeping in mind the fact that the thing you say you want most is to be able to keep your job, and be able to show up for it with sufficient energy. Because your body and brain have to have calories to keep up that basic energy, it’s worth it to push past that restrictive voice, and make the small changes we’ve discussed.” Connection means the doctor will insist on a warm, non-hierarchical, communicative relationship with the rest of the outpatient team, and will respect and reinforce the team’s messages.
Compassion is the second key trait. No patient with an eating disorder should have to tolerate someone whose bedside manner is impatient, rushed, accusatory, or blaming. In fact, I believe that a non-assumptive perspective is one of the best and most respectful ways a doctor can show compassion. Non-assumptive means the doctor doesn’t assume they know things about a patient, based on the patient’s race, sex, gender, eating disorder diagnosis, body weight, religion, age, etc. The fact is, eating disorders can occur in people of all shapes and sizes, of all ages, all genders, all races and religions. Compassion and patience are vital for the often intelligent, sensitive, anxious patients who have eating disorders. Eating disorders can take a long time to get better, and the course is a roller-coaster one. No one chooses an eating disorder (or would wish one on their worst enemy). Doctors must have compassion for the suffering and ambivalence experienced by those with eating disorders, and the challenges their loved ones face, if they are to be truly effective.
Commitment is the third key trait. Doctors receive little training about eating disorders. However, a worthy doctor should show a commitment to learning more and finding ways to help. There are terrific articles, books, online resources, and experts in the field (like me!) all too happy to help improve evidence-based, quality care for patients with eating disorders. As long as your doctor shows a willingness to learn and seek out these resources, they can do terrific good. However, resisting/rejecting this commitment to learn more can cause terrible harm. For instance, rapid weight loss, without underweight, can cause the same, and equally severe, medical problems as profound chronic underweight. I recently spoke with a patient who was losing weight rapidly due to a swallowing problem, and eating very little, but when her terrified therapist got her an urgent GI appointment, the doctors there said because her weight was normal, they weren’t concerned. This is a great example of assumptive thinking: “Because this young woman is of a normal weight, she can’t have a serious problem from an eating disorder.” Patients get dangerously missed in these situations.
In sum, I believe that a medical doctor, like a pediatrician (often better at treating eating disorders than doctors who treat adults!), family practitioner, internist, or adolescent medicine specialist, can have a positive impact on the overall care of patients with eating disorders and can be a great asset to the outpatient mental health/dietitian team. Even though many elements of our medical system can stack up to disempower patients and their families, strong advocacy for the right doctor is worth it. If the doctor really embodies the traits of connection, compassion, and commitment, you will be in good hands.