BRIEF REPORT

A National Survey of Eating Disorder Training Fauzia Mahr, MD1* Pantea Farahmand, MD2 Edward O. Bixler, PhD1 Ronald E Domen, MD1 Eileen M. Moser, MD1 Tania Nadeem, MD3 Rachel L. Levine, MD1 Katherine A. Halmi, MD4

ABSTRACT Objective: Eating disorders (EDs) result in the highest mortality rate of all psychiatric disorders, and in the United States, approximately one in twenty females suffers from an eating disorder. However, training provided within residency programs to address the needs of these patients is sparse. The objective of this study was to conduct a national survey that assesses the amount of EDs training for trainees across five ACGME accredited specialties: internal medicine, pediatrics, family medicine, psychiatry, and child and adolescent psychiatry. The results of the survey will be used to develop strategies to improve eating disorder education among residents. Method: Eight hundred eighty training coordinators were contacted using information available on the ACGME website and asked to complete the survey.

or elective rotations for EDs. Of the 123 programs offering rotations, only 42 offered a formal, scheduled rotation. Child and adolescent psychiatry offered the most clinical experiences, and pediatric programs offered the greatest number of didactic hours on EDs. Discussion: Training in EDs is limited. Simulated patient encounters, massive open online courses, web-based curricula, dedicated rotations and clinical experiences, didactic curricula, and brieftraining programs may help to improve eating disorder diagnostic and treatment C 2014 Wiley Periskills among trainees. V odicals, Inc. Keywords: national survey; training; eating disorders (Int J Eat Disord 2015; 48:443–445)

Results: Of the 637 responding programs, 514 did not offer any scheduled

Introduction Eating disorders (EDs) are common psychiatric disorders requiring timely diagnosis and treatment. While there is a lack of uniformity in the treatment of EDs across all disciplines, there is also a surprising lack of experience among psychiatrists. Deficiencies in educating general psychiatrists on the topic of EDs have resulted in additional lack of essential treatment skills and empathy for patients with EDs.1 Two Canadian studies revealed that most psychiatry residents find EDs training inadequate.2,3 Significantly, Ogg Accepted 6 July 2014 Supported by Departments of Psychiatry & Pediatrics at Hershey Medical Center. *Correspondence to: Fauzia Mahr, MD, Penn State Milton S Hershey Medical Center Psychiatry, Hershey, PA. E-mail: [email protected] 1 Penn State Milton S. Hershey Medical Center 500 university drive Hershey PA PO BOX 850 H073, 17033 USA Ph:717-531-8133 2 University of Connecticut. 263 Farmington Avenue, 2103 Farmington, CT 06030-2103, USA 3 Aga Khan University. Stadium Rd, Karachi 74800, Pakistan 4 Weill Cornell Medical College. 1305 York Ave, Manhattan, NY 10065, USA Published online 22 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22335 C 2014 Wiley Periodicals, Inc. V

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et al. reported that patients with EDs frequently visit their primary care physicians prior to receiving an ED diagnosis.4 There is an estimated lag of 5 years between a patient’s first visit to a physician’s office and the diagnosis of an ED. Such an interval may account for many lost opportunities for early treatment. Research supports the usefulness of formal EDs training to medical providers.5,6 Studies by Banas et al. noted that residents who have clinical experience treating patients with EDs during residency are more comfortable providing for this population after graduation.7 Unfortunately, there remain few published articles on the amount or type of training necessary to train psychiatry or primary care residents in EDs.8,9 Currently, a standardized guideline or curriculum is not available to residency programs to teach the topic of EDs.10,11 Furthermore, the Accreditation Council for Graduate Medical Education (ACGME) does not provide any specific curricula recommendations to residency programs for EDs training.12 To the authors’ knowledge, there are no published studies on the differences in training patterns across multiple medical disciplines. To evaluate the current training practices regarding EDs, a national needs assessment 443

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survey was conducted across all accredited residency programs in internal medicine, family medicine, pediatrics, psychiatry, and child and adolescent psychiatry.

Method This study was approved by the Institutional Review Board of the Pennsylvania State University Milton S. Hershey Medical Center. A survey was developed by the author in consultation with several ED specialists and training coordinators and was electronically sent to all program coordinators of the five ACGME-accredited medical disciplines of internal medicine, family medicine, pediatrics, general psychiatry, and child and adolescent psychiatry. Follow-up phone calls were also used. Contact information was obtained from the ACGME website for all programs listed in 2011–2012. Program coordinators were queried because they are knowledgeable about the residency program’s curriculum and often help organize the rotations and didactic experiences for trainees. For their participation program coordinators received a $5 gift card. The data collected were organized into Excel. Statistical analysis was accomplished using SPSS and descriptive analysis, one-way ANOVA, and Chi square.

Results Survey was sent to 1,248 training coordinators across five disciplines but 388 listings had either disconnected phone numbers, invalid email addresses, or had opted out of the survey monkey. Of the 880 that we were able to reach, 637 (72.3%) coordinators entirely or partially completed it. The number of respondents who completed the entire questionnaire was 596, and 42 partially completed it. Both complete and incomplete samples were included in the study. Question about specific ED training sites was asked, however the response rate was extremely low across all five specialties and these data were not included in compiled results. Geographically, the response was highest from the Northeast (201), and lowest from the Southwest (62). One hundred fifty-five programs from the Midwest, 139 from the Southeast, and 79 from the West responded. Interestingly, the Northeast programs also offered the highest number of opportunities for clinical rotations. Family medicine had the highest response with 201 out of all programs queried. Internal medicine was next with 175, general psychiatry had 113, and pediatrics had 103 responses out of the total num444

ber of programs queried. The child and adolescent psychiatry response was the lowest at 44. There was no significant correlation between region and the number of EDs training facilities. However, the great variation in survey response by specialty and geographic locations preclude an accurate assessment. The aggregated number of supervisors across all disciplines involved in treating patients with EDs across these disciplines was: 63 psychiatrists, 25 psychologists, 25 pediatricians, 12 family medicine physicians, 11 social workers, and 10 internists. A total of 514 training programs did not offer any scheduled or elective ED rotations. Of the 123 programs that offer rotations, only 42 offered a scheduled rotation. Our data showed that among the medical specialties providing rotations, only 3 of the internal medicine programs offered a scheduled rotation, and 13 offered an elective rotation. Only 11 of the pediatric programs offered a scheduled rotation, and 10 offered an elective rotation. With regard to general psychiatry, 12 programs offered a scheduled rotation and 24 offered an elective rotation. Of the child and adolescent psychiatry programs, 12 offered a scheduled rotation and 13 offered an elective rotation. Only 4 of the family medicine programs offered a scheduled rotation, while 21 offered an elective rotation. While the authors do not have data on the number of scheduled rotations that were full time assignments to ED units, the variation in the length of the rotations suggests that some of these rotations may consist of only a few hours of training per week. Four internal medicine programs offered rotations for less than one month, and eight programs offered rotations for one month. Five pediatric programs offered rotations for less than one month, 12 programs offered rotations for one month, and 2 programs offered rotations between 1 and 3 months. Ten general psychiatry programs offered rotations for less than one month, 18 programs offered rotations for one month, and 7 programs offered rotations between 1 and 3 months. Five child and adolescent psychiatry programs offered rotations for less than one month, 9 programs offered rotations for one month, 1 program offered a rotation for 1–3 months and 6 programs offered rotations for greater than three months. Nine family medicine programs offered rotations for less than one month, 15 programs offered rotations for one month, and 1 program offered a rotation between 1 and 3 months. Overall, larger residency programs offered greater opportunities for ED training. International Journal of Eating Disorders 48:4 443–445 2015

NATIONAL SURVEY OF EATING DISORDER TRAINING

The number of hours of formal EDs training was also investigated; it included verbal questioning about case conferences, grand rounds, and lectures. To avoid ambiguity, program coordinators were specifically asked about lectures on bulimia and anorexia, excluding obesity or “fussy eaters.” Overall, 14.5% of responding programs provided no formal didactics about EDs. Internal medicine provided the least number of didactic teaching hours with a mean of 1.94 hurs. Pediatrics provided the highest amount of didactic teaching with a mean of 5.25 hours. However, the standard deviation was 12.6 hrs. (One pediatric program provided 120 hours). General psychiatry and child and adolescent psychiatry were not statistically different and had means of 4.00 and 4.05 hrs of didactic teaching, respectively. Family medicine provided a mean of 3.55 hrs.

Innovative strategies can help close the existing resource gap for experts and supervisors in the field of EDs to improve knowledge, skills, and attitudes of trainees towards patients struggling with EDs. For example, developing and disseminating MOOCS (massive open online courses), simulated patient encounters, web-based curricula, collaborative learning experiences for trainees across disciplines, use of resources at the Academy of Eating Disorders website, brief training seminars, and distant learning strategies are worthwhile options to consider. As in the case of addictive disorders, where there is now a mandate for payment of screening, intervention, and referral to a specialized treatment center (SBIRT), the primary care setting should have a similar protocol for EDs. Additional studies will be needed to assess the impact of existing training on positively altering knowledge, skills, and attitudes of the trainees.

Discussion

The authors acknowledge Dr. Roger Meyer’s invaluable feedback and mentoring during the development and execution of this project. None of the authors have any conflict of interest to disclose.

The results of this survey underline a need for improving the educational experience related to EDs in residency training programs across multiple disciplines. Training endeavors during residency may help to improve knowledge, skills, and attitudes toward patients with EDs. Factors impacting EDs training may include lack of experts who can provide supervision, geographic locations, and lack of standardized guidelines. Geographic location is significant because some locations may not see a large population of patients with EDs. These factors may also account for the lack of uniformity in EDs training. Limitations of this study include the lack of inquiry into the intensity of resident supervision, specifics about the professional specialties of teachers delivering the didactic presentations, and specifics regarding collaborative teaching efforts. Additionally, there may be formal EDs curricula taught in other venues that were not captured. Gathering data about the actual assignments during a rotation would have been useful but was beyond the scope of this initial study. We surveyed program coordinators, as they are often involved in the scheduling of rotations and didactics; however, they may not be aware of any bedside teaching that might occur outside of scheduled rotations. Finally, further clarification of the specialty of other educators (e.g., adolescent medicine specialists) would have been useful to ascertain whether or not other professionals are also involved in resident education and supervision.

International Journal of Eating Disorders 48:4 443–445 2015

References 1. Kuyck VK, Gerard N, Laere VK, Casteels C, Pieters G, Gabriels L, et al. Towards a neurocircuitry in anorexia nervosa: Evidence from functional neuroimaging studies. J Psychiatr Res 2009;43:1133–1145. 2. Ghadirian AM, Leichner P. Psychiatric residents’ educational experiences and attitudes toward eating disorders. Can J Psychiatry 1990;35:254–256. 3. Williams M, Leichner P. More training needed in eating disorders: A time cohort comparison study of Canadian psychiatry residents. Eat Disord 2006; 14:323–334. 4. Ogg EC, Millar HR, Pusztai EE, Thom AS. General practice consultation patterns preceding diagnosis of eating disorders. Int J Eat Disord 1997;22:89– 93. 5. Gurney VW, Halmi KA. An eating disorder curriculum for primary care providers. Int J Eat Disord 2001;30:209–212. 6. Halmi KA. Perplexities and provocations of eating disorders. J Child Psychol Psychiatry 2009;50:163–169. 7. Banas DA, Redfern R, Wanjiku S, Lazebnik R, Rome ES. Eating disorder training and attitudes among primary care residents. Clin Pediatr (Phila) 2013; 52:355–361. 8. Michaud PA, Stronski S, Fonseca H, Macfarlane A; EuTEACH Working Group The development and pilot-testing of a training curriculum in adolescent medicine and health. J Adolesc Health 2004;35:51–57. 9. Williams M, Haverkamp BE. Identifying critical competencies for psychotherapeutic practice with eating disordered clients: A Delphi study. Eat Disord 2010;18:91–109. 10. Jones J, Larner M. An audit of training, competence and confidence among clinicians working in eating disorder services. Mental Health Pract 2004;8: 18–22. 11. Kick SD, Morrison M, Kathol RG. Medical training in psychiatry residency, a proposed curriculum. Gen Hosp Psychiatry 1997;19:259–266. 12. Information extracted from accredited programs. Available at https://www. acgme.org/acgmeweb/tabid/172/GraduateMedicalEducation/AccreditedProgramsandSponsoringInstitutions.aspx. Accessed 2011–2012.

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A national survey of eating disorder training.

Eating disorders (EDs) result in the highest mortality rate of all psychiatric disorders, and in the United States, approximately one in twenty female...
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