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Physicians’ perspectives on the treatment of patients with eating disorders in the acute setting

Physicians’ perspectives on the treatment of patients with eating disorders in the acute setting Background: Hospitalisation for an eating disorder is rare, however treatment in the acute medical setting can be a life-saving admission. While the multidisciplinary team delivers overall patient care, medical decisions are the responsibility of the treating physicians. Treatment decisions directly impact on patient care and outcomes. This study aimed to explore the considerations that influence the medical decisions of physicians when treating patients with eating disorders in the acute setting. Method: Semi-structured interviews were conducted with ten medical physicians who had previously treated eating disorders on a general medical unit in two Australian tertiary hospitals. An interview schedule, based on the literature and four relevant domains from the Consolidated Framework for Implementation Research, was developed. Interviews were audio recorded, transcribed verbatim and analyzed thematically. Coding and interim themes and sub- themes were developed by two dietitian researchers; these were further refined through researcher discussion and triangulation with two additional dietitian researchers. Results: Ten doctors were interviewed (3 consultants (1 adult general medical and 2 paediatricians: 13–16 years medical experience), 2 registrars (4–7 years experience), 1 resident (1 year experience), and 4 interns (< 1 year experience). Doctors described memorable patient cases, related to hospital stays over several weeks. Interviews ranged in length from 58 min to 91 min. Four themes (with five sub-themes) were developed: 1) navigating uncertainty (focusing on processes and goals and seeking information), 2) being “the good doctor” (doing the right thing), 3) seeing the big picture (depending on key players and considering short and long-term), and 4) involving family and patient. Conclusions: Non-specialist physicians described challenges in the treatment of eating disorders in the inpatient setting. They take a holistic approach that considers both short and longer-term goals, relying on specialist colleagues, the wider multidisciplinary team and sometimes family members to guide treatment decisions during admissions on general medical wards. Additional support, education and training centered on the key themes may increase physicians’ confidence and ability to make effective treatment decisions for this patient group. The results are relevant to all health professionals working in this field to better understand the priorities of medical physicians and to support them to achieve positive outcomes in the inpatient treatment of patients with eating disorders. Keywords: Eating disorders, Inpatients, Physicians, Patient care team, Qualitative, Medical, Decision making * Correspondence: dreidlin@bond.edu.au Faculty of Health Sciences and Medicine, Bond University, University Drive, Robina, QLD 4226, Australia Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 2 of 9 Plain English summary ensure optimal and consistent care of patients. In the Hospital treatment of eating disorders can be challenging United Kingdom, the National Institute for Health and for both patients and health care professionals. Physicians Clinical Excellence has recently developed new guidelines were of interest in this study, as they are responsible for for recognition and treatment of eating disorders, includ- the medical decisions made in the treatment of patients ing in the acute environment [13]. Clinical practice guide- with eating disorders during a hospital admission. Typic- lines from the American Psychiatric Association cover all ally, these patients are admitted to general medical wards, eating disorder diagnoses [10]; and in Australia, there are rather than specialist psychiatric wards. This research sets a range of similar clinical guidelines including those pro- out to understand physicians’ experiences when caring for duced by the Queensland Eating Disorder Outreach Ser- patients admitted to hospital for urgent, often life-saving, vice [14]. The aim of these guidelines is to provide health treatment. Ten physicians were interviewed about their professionals with a framework for daily medical measure- experiences with eating disorder patients. Key themes ments and behavioural management techniques for were developed to explain the underlying reasons for phy- patients [14]. However, the uptake of guidelines is known sicians’ decisions in the treatment of these patients, their to be inconsistent and dependent on a range of factors in- challenges and how they overcome these. Four themes cluding awareness and effective implementation [15]. (and five sub-themes) were 1) navigating uncertainty The experiences of nurses, dietitians, psychiatrists and (focusing on processes and goals and seeking informa- primary care physicians working with patients with eat- tion), 2) being “the good doctor” (doing the right thing), 3) ing disorders have previously been explored and assessed seeing the big picture (depending on key players and con- across quantitative and qualitative studies [16, 17]. How- sidering short and long-term), and 4) involving family and ever, hospital physicians – that is, those medical profes- patient. Physicians relied on family members, specialist sionals working in general medical rather than specialist colleagues, nurses, dietitians and other allied health psychiatric or mental health wards - have not previously professionals to ensure safe, evidence-based treatment been studied as a homogenous sample. Given the chal- that was focused on both short and longer-term recov- lenges highlighted across other health profession groups, ery goals. and the key role of physicians in acute medical wards in managing these patients, further insight into the reasons Background for treatment decisions in this patient group, including Eating disorders are characterized by ongoing abnormal those which may diverge from guidelines, is warranted and distorted eating habits or behaviours [1]. It is esti- [18]. For other health professionals, a better understand- mated that 30 million people in the USA, 1.25 million ing of the considerations informing the treatment deci- people in the United Kingdom and 1 million people in sions of physicians could support a more team focused Australia, are affected by an eating disorder [2–4]. Eat- approach to the care of patients with eating disorders ing disorders have the highest suicide and co-morbid admitted to non-specialist wards. This study aimed to mental illness rate of all mental health illnesses and are explore the considerations that influence the medical de- predominately managed in the community [5, 6]. Al- cisions of physicians when treating patients with eating though only a minority of people with an eating disorder disorders in the acute setting. are hospitalized [7], acute medical treatment is focused on medical stabilization, which can be lifesaving, and an Methods important part of an individual’s recovery. The most This was an interview study targeting physicians involved common diagnoses to require admission for medical in the treatment of eating disorders in two acute metro- stabilization are Anorexia Nervosa and other restrictive politan hospitals in South East Queensland, Australia. eating disorders [8]. Such treatment may include electro- Interviews were chosen as the most appropriate method lyte replacement, monitoring and correction of refeeding for exploring their experiences with eating disorder pa- syndrome, electrocardiograph monitoring, and oral or tients, in order to better understand the treatment deci- tube feeding [9, 10]. sions made by individual physicians, whilst providing a Caring for this patient group within the acute medical safe space to express potentially sensitive information setting is known to be challenging [11]. There is a need about their challenges and areas of uncertainty in treating for a cohesive approach encompassing medical and this patient group. An interview schedule (Additional file 1: psychological management, and to manage the patient’s Table S1) was developed by the research team to elicit ambivalence towards medical intervention [11]. A in-depth responses from the physicians to inform the multidisciplinary team approach and the use of guide- research aim. Questions were developed based on the lit- lines can facilitate treatment and overcome challenges erature and according to four relevant domains from the [12]. A range of guidelines for the treatment of people Consolidated Framework For Implementation Research with eating disorders across all settings are available to (CFIR): (1) characteristics of the individuals involved, (2) Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 3 of 9 process, (3) outer setting, and (4) intervention characteris- review guidelines [25] (Additional file 2:Table S2). Ethical tics [19]. To provide richness of data through real case vi- approval was obtained from the (Bond University Human) gnettes, physicians were asked to recall and describe two Research Ethics Committee prior to commencing recruit- patient cases they had previously treated: 1) a patient with ment, Ref: 015660. an eating disorder treated voluntarily and 2) another pa- tient treated involuntarily [20]. Prior to data collection, a Findings pilot interview was conducted with a medical intern, not Eleven physicians were recruited, ten were interviewed. eligible to participate, to refine the interview schedule. One physician provided written informed consent, but A convenience sample was sought, due to the known was deemed ineligible to participate due to having no ex- difficulties in recruitment of physicians to research stud- perience of treating eating disorders in an acute medical ies [21]. All eligible physicians who were willing and ward. Participating physicians had a range of medical available were invited to participate. Physicians from all experience; three attending physicians (one adult general experience levels currently working at the hospitals were medical and two pediatricians: 13–16 years medical ex- eligible, provided they had previously treated a patient perience), two fellows (4 to 7 years medical experience), with an eating disorder in an acute medical setting (such one junior resident (>1 year medical experience), and four as a general medical ward admission). Medical students, interns (<1 year medical experience). During the inter- nursing and allied health staff were excluded. One re- views, participants chose patient cases to describe in searcher recruited eligible physicians in a brief informa- detail, in response to the questions posed in the interview tion session at medical handover meetings and teaching schedule. The majority of physicians described experi- sessions at both hospitals. Recruitment snowballing was ences related to people with anorexia nervosa; one partici- used: once physicians had participated, they were then pant described their experience with a patient with asked to pass on the study information to potentially eli- bulimia nervosa. gible colleagues. Signed and informed consent was ob- Four themes (navigating uncertainty, being the good tained before each interview. doctor, seeing the big picture, involving patient and fam- Face-to-face semi-structured interviews were conducted ily) and five sub-themes (focusing on processes and goals, by one researcher in a private room at either hospital site. seeking information, depending on key players, consider- Interviews were audio recorded using a digital voice ing short and long term, and doing the right thing) were recorder and transcribed verbatim by one researcher and developed (Fig. 1). checked by a second researcher against the recordings for accuracy and to facilitate immersion in the data [22]. To Theme 1: navigating uncertainty ensure anonymity and confidentiality, potentially identifi- Within this theme, three sub-themes were developed: 1) able data disclosed during the interviews were removed focusing on processes and goals, 2) depending on key during transcription and replaced with pseudonyms, players and 3) seeking information. Physicians described including details of names, locations, and patient details. the treatment of patients with eating disorders as outside Inductive, line-by-line analysis of data was undertaken im- of their comfort zone. When describing cases, physicians mediately following transcription of each interview. The were more likely to express confidence about the objective interviewer recorded field notes after each interview to aid medical tests and interventions, but were less confident the analysis, and data collection ceased when there was communicating with the patient and behavioural manage- consensus among two of the researchers that the study’s ment. The physicians working in adult wards related this aim had been addressed. Thematic analysis followed a uncertainty to the relatively rare experience of treating pa- five-step process as recommended by Braun and Clarke: 1) tients with eating disorders. data familiarization, 2) initial coding, 3) theme development 4) theme review (whereby preliminary themes were applied “…they’re very few and far in between…So, it doesn’t to all codes until theoretical sufficiency was reached) [23] happen often for us.”– Physician #1. (male, attending and 5) theme defining and naming [24]. Microsoft Word physician, 14 years medical experience). was used to manage the data. Researcher triangulation en- sured trustworthiness during thematic analysis: coding and Whilst physicians working in pediatric wards did not preliminary themes were developed, discussed at length comment on the rarity of eating disorder patients, they still and agreed between two researchers, the selected exemplar described the challenges in navigating this uncertainty: quotes were then presented and discussed until there was agreement on the final themes and sub-themes amongst all “Sometimes I do wonder whether the way I approach four researchers (three of whom were dietitians, and the things or whether the way I say certain things, whether fourth of whom was a dietetic student). The manuscript that’s actually the best way or not.”– Physician #10 was prepared according to the RATS qualitative research (female, pediatrician, 13 years medical experience) Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 4 of 9 Fig. 1 Summary of themes and sub-themes and their interrelationships Physicians, from adult and pediatric units, described unsafe medical status was the physicians’ main priority their uncertainty about management of eating disorders as in treatment: due to eating disorders not being “black and white” -the decisions they faced, in particular behavioural manage- “…obviously for a patient that’sinthe acute ment decisions, were subjective. Physicians described how setting, you have to be worried about refeeding they would navigate this uncertainty by seeking informa- syndrome. And you wanna do that safely.”– tion: for example, referring to a guideline or protocol, the Physician #8 (female, intern, less than one year evidenced-based literature, and other health professionals medical experience). from the multidisciplinary team whom they identified were key players in effective treatment, including specialist Physicians described their responsibility to do the right colleagues in the liaison psychiatric services, dietitians, thing by the patient, the family and other treating health psychologists and nurses. professionals. This included meeting the expectations of the patient and the family, and answering complex ques- “…talking to my other consultant colleagues, tions proposed by family: especially with regard to approaching family and conflicts between medical staff and family “It’s difficult because they have so many straight, and how they’ve managed them, influences in closed questions that they want answers to that never a way cause they’ve done it more often than have straight answers…But, I feel like we don’t always me.”– Physician #1 (male, attending physician, tell them what they expect to hear…”- Physician #2 14 years medical experience – referring to (male, junior resident, 1 year medical experience). liaison psychiatric services colleagues in the hospital). However, there was one deviant case, a general med- ical attending physician, who described how he would only focus on what he believed was right for the patient, Theme 2: being “the good doctor” even if this meant ignoring the family’s demands and Within this theme there were two sub-themes: 1) doing protests, which in some cases was difficult to do: the right thing and 2) seeking information. Physicians described that fulfilling “the good doctor” role was an in- “…the main thing that makes me determine what to ternal drive to do what is best for their patient and pa- do with a patient is what’s going to be best for them tient safety. The elimination of the cause of the patient’s and not what’s best for the family, or for anyone else.” Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 5 of 9 – Physician #1. (male, attending physician, 14 years followed up with long-term care then the patient would medical experience). not recover. To ensure long-term care was applied one physician described how this influenced her discharge Physicians described that being “a good doctor” also planning for patients: included being a life-long learner. Treatment of eating disorders was described as being only ‘briefly touched “…my goals are generally short-term goals, so I wanna on’ in medical school, thus physicians often identified make them safe enough. My long-term goals with these eating disorder issues as something of a gap in their patients is to provide them with a plan and then a knowledge and experience. During medical school, phy- support network which would usually include an sicians described that the importance of seeking infor- outpatient psychologist and dietitian.” – Physician #5 mation from credible sources to guide practice was (female, fellow, 7 years medical experience). instilled in them: Re-admissions were expressed as one of the many “...if, you know, we’re ordering an investigation or challenges to treating this patient group because physi- something and I don’t really understand why, if I don’t cians then felt that their own previous treatment at- get the opportunity to ask someone more senior then I tempts had failed. One physician felt that the reason for generally like to sort of look into that myself…” – re-admissions was because time between discharge and Physician #6 (intern, female, <1 year experience). follow-up appointments in the community was too long, and many patients were being re-admitted to hospital in that time: Theme 3: seeing the big picture Within this theme were two sub-themes, 1) depending “So, you discharge someone, cool, we’ve got you to a on key players and 2) considering short and long-term. good BMI. They start to go yeah; okay I think we In this theme, physicians spoke of the importance of might win this one… your outpatient appointment’sin having an overview of all aspects of care as vital in the two weeks or three weeks with psychology... In that two patient’s treatment. Physicians described that from ad- weeks they’re back in again.”– Physician #2. (male, mission, through to transfer (for example to an inpatient junior resident, 1 year medical experience). psychiatric unit within the hospital) and discharge, con- sidering the patient’s condition from multiple angles, not just a single variable such as body mass index, assisted Theme 4: involving family and patient in their decision-making: This theme encompassed two components: firstly, the in- volvement of family in treatment and decision-making. “I don’t think [admission] is always just a number... Physicians working on pediatric wards described that in- it’s always a picture of things.”– Physician #2. (male, volving the patient’s parents was mandatory. Physicians junior resident, 1 year medical experience). treating adults described that the family was only involved in treatment with the patient’s consent. However, both de- Physicians described this overarching approach included scribed that family could be a ‘double-edged sword’.On short and long-term goals, but also included collaboration one-hand family was identified as a useful tool in treat- with a range of health professionals from the multidiscip- ment, such as admitting the patient to hospital, and their linary team. Physicians universally agreed that they could role in family-based therapies. When family were per- not treat a patient with an eating disorder alone. For their ceived as supportive and able to contribute to treatment, patients with eating disorders they made referrals to physicians readily involved them: specialists to assist with treatment, including a psychiatrist and dietitian. The physicians demonstrated respect to- “…they’re going to be the ones to keep an eye out for wards the other disciplines, so long as these other health warning signs. So, it’s important to involve them in professionals fulfilled their role in treatment. their care as well.” – Physician #5 (female, fellow, 7 The sub-theme “short and long-term” encompassed all years medical experience). aspects of treatment. Physicians detailed that their pa- tients typically spend several weeks on a general medical On the other hand, physicians described that family ward, reflecting the longer length of stay for this patient could also be detrimental to treatment. Physicians empa- group (a mean of almost 20 days compared to 2.9 days thized with the family, and perceived the family had the for other admissions in Australia) [7]. They described patient’s “best interest at heart” yet were not always able their role in medical stabilization of the patient as only a to express this constructively. Physicians described expe- temporary fix, acknowledging that if discharge was not riences of family members who were hostile towards the Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 6 of 9 diagnosis and treatment plans, but at times seemed to care physicians and to support them in their treatment of begrudgingly welcome them into treatment decisions. patients with eating disorders. The physicians in this study identified patients with eat- “…So I think it’s…more important… than your ing disorders as unusual, describing the relative rarity of regular run of the mill medical patient to be admissions as a key contributor to their uncertainty when a bit more careful about the family…They can making treatment decisions. This perception of ‘rarity’ be really supportive and really helpful. But at appears to be real, with the majority of treatment con- the sametimetheycan be quite detrimentaltoo.” – ducted in outpatient and community settings rather than Physician #3. (male, intern, less than one year inpatient admissions [7]. The observation that people with medical experience). eating disorders present for treatment in small numbers is consistent with results from a qualitative study in the UK, The second component to this theme was involving the which explored the experiences of a range of health pro- patient. How the physicians involved the patient in treat- fessionals providing inpatient and outpatient care for ment was highly variable. Physicians described the pa- people with eating disorders. This study also found that tient’s capacity to make their own treatment decisions as participants working on a general medical ward felt they more likely if patient decisions aligned with those of the were lacking the experience to effectively treat people with doctor. From the physicians’ perspective patients were eating disorders due to low admission rates [6]. Similarly, generally expected to comply with treatment. However, in the same researchers interviewed general practitioners the case of eating disorders, the physicians also described who described this patient group as small in number, but anticipation of “non-compliance”. They described treat- high in complexity [6]. ment of patients with eating disorders as easier if the pa- The finding that physicians rely on practice guidelines tient had insight into their illness, where insight referred to manage their uncertainty when making treatment to a patient’s perception and knowledge of their mental decisions is perhaps not surprising. A guideline for the health illness. The physicians described the patient’s inpatient medical management of a patient with an eat- insight, or lack of insight, would contribute to the uncer- ing disorder is available to physicians working in the tainty and challenges of treatment: adult and pediatric wards within the health district studied [14, 26] although it was clear during the inter- “…it can be challenging with the patients who views that different physicians used different guidelines, don’t have the insight into their illness, because andsomewereunaware of theguideline.Somedoctors they don’t necessarily want your help, that can be relied on more senior colleagues and/or other health a challenge.”– Physician #4 (male, intern, less than professionals to guide their treatment decisions, rather than year medical experience). the guideline. Protocols and guidelines aim to support health professionals in facilitating treatment to overcome potential challenges with eating disorders [14]. They have Discussion been identified as useful for doctors and other health pro- This study set out to explore the considerations of phy- fessionals to overcome challenges and barriers, such as sicians in their treatment of patients with eating disor- communication and the complexity of individualized man- ders, focused on those that influence medical decisions agement in patients with eating disorders in the acute med- during acute hospital admissions. Key findings were ical setting [27]. Additionally, it has been suggested that the captured in the four themes and five subthemes devel- less experienced the health professional is in treating a con- oped, which highlighted the uncertainties in treatment dition, the greater the reliance on guidelines in treatment decisions, beneficence of physicians in wanting to do [15]. However, physicians in the present study expressed a what was best for their patients, with an understanding that reliance on guidelines regardless of their experience level. this requires the physicians to think beyond the immediate The commitment to lifelong learning by physicians in acute problems. Physicians identified that support in the this study reflect professional expectations of continuing form of treatment guidelines and evidence, along with the professional development and evidence-based medicine advice of more experienced colleagues and the wider team [28, 29]. Knowledge of eating disorders and of appropri- were critical to their treatment decisions. They described ate acute medical treatment is vital for physicians to key challenges they faced due to the relative rarity of eating effectively manage patients with eating disorders. Re- disorder admissions, the need to tailor the treatment ac- search has shown that insufficient knowledge of eating cording to the patient and their level of insight, and the key disorders can result in lowered confidence in treating role of family as potential enablers of successful treatment. patients, which is consistent with our findings [18, 29]. These findings are relevant to all health professionals work- Opportunities for professional development in effective ing in this field to better understand the priorities of acute treatment and relevant guidelines for this patient group Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 7 of 9 may go some way to meeting the needs of physicians in that the family played in effective treatment. Socially ac- the acute setting, perhaps in an interdisciplinary setting to ceptable behaviour for a patient is usually to seek and encourage sharing and understanding within the multidis- accept help from a health professional [33]. Eating dis- ciplinary team. order patients typically go against this norm - poor The beneficence of physicians in this study was insight, ambivalence and refusal of professional help are highlighted by their motivation to be the “good doc- key characteristics of patients with eating disorders, in tor”. This likely reflects the altruistic nature of those particular those with Anorexia Nervosa [30]. Other that choose medicine as a career, along with the pro- health professionals have noted the propensity for pa- fessional and ethical conduct codes imbued in medical tients to refuse treatment options as complicating treat- school training and upheld by physicians in their prac- ment decisions in eating disorder care, and described tice [28]. The responsibility to do what is right by the the difficulty of having to treat someone who refuses patient, and to meet expectations placed on the physi- care [34]. cians by both patient and parent (family) has been pre- Involving family as a partner in discussions and treat- viously described. Health professionals interviewed in ment of a patient is the crux of patient- and family- a UK study expressed intentions to do what is best by centered care [35]. Family members are also a valuable their eating disorder patients, but noted uncertainty source of information and play an important part in the about the correct course of action for their individual long-term care of the patient. The hesitation to involve patients [6]. The influence of perceived patient and family was also previously described by health profes- family expectations of the physician during inpatient sionals who worked with children and adolescents with treatment was also reported in an interview study of eating disorders in a range of settings. Participants in health professionals working in an adult eating dis- the current study found the decision to involve family order inpatient service, where participants felt it was as more difficult than the objective medical decisions difficult to meet high expectations of care and the re- [36]. Support for physicians to optimize communica- covery process [11]. tion with patients and family, possibly through training The physicians in this study were grateful for the input or professional mentoring, may result in more inclusive of other health professionals including mental health spe- treatment decisions that support acute recovery and ef- cialists to inform their treatment decisions, and supports fective discharge. practice guidelines and literature which advocate multidis- ciplinary team working as the most effective approach to Strengths and limitations treatment [17, 30]. Key members of the multidisciplinary A key strength of this study was the successful recruitment team for eating disorders include dietitians, psychologists of physicians across two hospitals in the same health dis- and medical practitioners [14]. Although each individual trict. Physicians are known to be a difficult population to specialist has a crucial role in eating disorder treatment, recruit for research due to many reasons, including de- the ineffectiveness of isolated treatment has been noted manding schedules, which occurred in this study [37]. The [13, 31]. These findings should strengthen the role of decision to only include general medical physicians meant health professionals working with physicians during acute an initial, smaller pool to recruit from, but also provided a care admissions. unique homogenous participant group who represent key The physicians in this study described readmissions decision makers in the medical treatment of eating disorder as setbacks, and attributed these in part to untimely fol- patients admitted to hospital. The information gathered low up of patients after discharge. Patients with eating from physicians who participated in this study provided disorders have high rates of relapse and readmission a range of experience and insight into the research [11]. Delayed follow-up has also been described as a prob- question. With this smaller sample size, theoretical lem in the primary care setting, where general practitioners sufficiency (whereby new data was able to be accommo- described lengthy referral waiting lists [32]. Ensuring timely dated within the developed themes without further modifi- and intense follow-up treatment has been identified as one cations) was achieved [23], although it is possible that with method of decreasing rates of relapse and readmissions a larger sample size, a greater number or modified themes [30]; other suggestions include training, primary care refer- may have been developed. However, interviews were ad- rals and continuity of care as key components of effective equate in length, about 1 h each – remarkable considering careintheprimarycaresetting [6]. Our findings indicate the busy schedules of the participants - and produced rich physicians’ frustration and erosion of confidence in the data into the experiences and influences of the physicians treatment of eating disorder patients as a result of this re- involved. The patient cases described by physicians were admission cycle. chosen by them, and it is possible that the cases described The complexity of care of people with eating disorders didnot reflectthe full gamutofadmissionstoageneral extended to the patient and their insights, and the role medical ward such as short admissions for electrolyte Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 8 of 9 correction only. In addition, the descriptions were limited Acknowledgements The authors would like to acknowledge and thank the physicians who contributed to details that the doctor could recall during the interview, their time and professional experiences to this study, and thank all those involved in and in some instances, these may have been unclear or recruitment. misremembered. For example, some physicians could not Funding recall whether treatment was involuntary or voluntary, but There was no financial aid or funding for this project. nevertheless chose a case because they were comfortable to discuss it in detail. Analysis was conducted by researchers Availability of data and materials The datasets generated during and/or analysed during the current study are who were all dietitians or a student dietitian, and we not publicly available due to participants in this study not providing explicit acknowledge that this almost certainly influenced the consent for transcripts to be shared but are available from the corresponding final themes developed and presented here; analysis by author on reasonable request. Requests for data to be made available will be referred to the institution review board for consideration. researchers with a more diverse professional back- ground may have resulted in different interpretations of Authors’ contributions the data. The analysis adds insight into the thoughts All authors contributed to the research conception, study design and ethical approvals. ARD undertook recruitment and data collection. All authors contributed and concerns of treating physicians, we believe for the to data analysis and interpretation, as well as manuscript preparation. ARD wrote first time. the first draft of the manuscript. All authors critically reviewed the manuscript and The study findings highlight future opportunities for approved the final version for submission. research and service improvements in this area. They Authors’ information emphasize the need to build physicians’ (and medical stu- Three of the authors, SB, LD and DPR currently work or have previously dents’) knowledge and confidence in working with pa- worked in acute hospital settings with eating disorder patients. DPR is an Accredited Practising Dietitian (Australia) and a Registered Dietitian tients with eating disorders. Training for physicians, and (UK), SB and LD are Accredited Practising Dietitians (Australia), and ARD perhaps also allied health colleagues supporting them, that was a student dietitian in a Master of Nutrition and Dietetic Practice is focused on awareness of existing resources, including program during the study. guidelines and protocols for inpatient treatment, and Ethics approval and consent to participate skills to manage the challenges of working with patients Approval was gained from (Bond University Human) Research Ethics Committee, with eating disorders, their families and colleagues is Ref: 015660. All participants were provided with a Participant Information Sheet and Consent Form and signed prior to commencement of interviews. warranted. Conducting a similar study with other health professionals involved in the treatment of eating Consent for publication disorders in the acute setting, such as nurses, dietitians Not applicable. and psychologists, could add to the more effective im- Competing interests plementation of guidelines within acute medical wards. The authors declare that they have no competing interests. Conclusions Publisher’sNote The physicians viewed the multidisciplinary team ap- Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. proach as vital to the treatment of eating disorders in an acute setting, which should instill confidence in other Author details health professionals working in this clinical area. Further, Faculty of Health Sciences and Medicine, Bond University, University Drive, Robina, QLD 4226, Australia. Gold Coast Hospital and Health Services, their awareness of the physicians’ experiences, including Southport, Australia. an understanding of the challenges physicians face with this patient group, should ensure other members of the Received: 19 August 2018 Accepted: 5 December 2018 multidisciplinary team can better support the medical team to more effectively treat them in the acute setting. References The results are relevant to all health professionals work- 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed; 2013. ing in this field to better understand the priorities of 2. Butterfly Foundation for Eating Disorders. Investing in need: cost-effective acute care physicians and to support them in their treat- interventions for eating disorders. Sydney: The Butterfly Foundation; 2015. ment of patients with eating disorders. Such awareness 3. National Association of Anorexia Nervosa and Associated Disorders. Eating disorder Statistics 2017. Available from: https://anad.org/education-and- is likely to improve team dynamics as well as outcomes awareness/about-eating-disorders/eating-disorders-statistics/. for this patient group. 4. Beat Eating Disorders. Statistics for Journalists: How many people in the UK have an eating disorder? n.d. Available from: https://www. beateatingdisorders.org.uk/media-centre/eating-disorder-statistics. Additional files 5. Hay PJ, Claudino AM, Touyz S, Abd Elbaky G. Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa. Additional file 1: Table S1. Interview guide with rationale for inclusion. Cochrane Database Syst Rev. 2015;(7):Cd003909. https://doi.org/10.1002/ (DOCX 31 kb) 14651858.CD003909.pub2. 6. Reid M, Williams S, Burr J. Perspectives on eating disorders and service Additional file 2: Table S2. Qualitative research review guidelines – provision: a qualitative study of healthcare professionals. Eur Eat Disord Rev. RATS. (DOCX 23 kb) 2010;18(5):390–8. Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 9 of 9 7. Butterfly Foundation for Eating Disorders. Paying the price: the economic 33. Bradby H. Medicine, health and society: a critical sociology. Los Angeles: and social impact of eating disorders in Australia. Sydney: The Butterfly SAGE; 2012. Foundation; 2012. 34. Walker S, Lloyd C. Barriers and attitudes health professionals working in 8. Health and Social Care Information Centre. Provisional monthly topic of eating disorders experience. Int J Ther Rehabil. 2011;18(7):383–90. interest: Eating disorders. In: Hospital Episode Statistics (HES). Leeds: NHS 35. Gallo KP, Hill LC, Hoagwood KE, Olin S-cS. A narrative synthesis of the Digital, United Kingdom National Health Service; 2016. components of and evidence for patient- and family-centered care. Clin 9. Gaudiani JL, Sabel AL, Mascolo M, Mehler PS. Severe anorexia nervosa: Pediatr. 2016;55(4):333–46. outcomes from a medical stabilization unit. Int J Eat Disord. 2012;45(1): 36. Lafrance Robinson A, Kosmerly S. The influence of clinician emotion on 85–92. decisions in child and adolescent eating disorder treatment: a survey of self and others. Eat Disord. 2015;23(2):163–76. 10. Yager J, Devlin MJ, Halmi KA, Herzog DB, Mitchell IIIJE, Powers P, et al. 37. Asch S, Connor SE, Hamilton EG, Fox SA. Problems in recruiting community- Practice guideline for the treatment of patients with eating disorders third based physicians for health services research. J Gen Intern Med. 2000;15(8): edition. Am J Psychiatry. 2006;163(7):1-128. 591–9. 11. Davey A, Arcelus J, Munir F. Work demands, social support, and job satisfaction in eating disorder inpatient settings: a qualitative study. Int J Ment Health Nurs. 2014;23(1):60–8. 12. Warren CS, Crowley ME, Olivardia R, Schoen A. Treating patients with eating disorders: an examination of treatment Providers’ experiences. Eat Disord. 2008;17(1):27–45. 13. National Institute for Health and Care Excellence. Eating disorders: recognition and treatment. London: NICE; 2017. 14. Royal Brisbane and Women’s Hospital. A guide to admission and inpatient treatment for people with eating disorders in Queensland. Brisbane: Metro North Hospital and Health Service; 2014. 15. Francke AL, Smit MC, de Veer AJ, Mistiaen P. Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak. 2008;8:38. 16. Banas DA, Redfern R, Wanjiku S, Lazebnik R, Rome ES. Eating disorder training and attitudes among primary care residents. Clin Pediatr. 2013;52(4):355–61. 17. Seah XY, Tham XC, Kamaruzaman NR, Yobas P. Knowledge, attitudes and challenges of healthcare professionals managing people with eating disorders: a literature review. Arch Psychiatr Nurs. 2016;31(1):125-36. 18. Currin L, Waller G, Schmidt U. Primary care physicians’ knowledge of and attitudes toward the eating disorders: do they affect clinical actions? Int J Eat Disord. 2009;42(5):453–8. 19. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. 20. Douzenis A, Michopoulos I. Involuntary admission: the case of anorexia nervosa. Int J Law Psychiatry. 2015;39:31–5. 21. VanGeest JB, Johnson TP, Welch VL. Methodologies for improving response rates in surveys of physicians: a systematic review. Eval Health Prof. 2007; 30(4):303–21. 22. Hennink M, Weber MB. Quality issues of court reporters and transcriptionists for qualitative research. Qual Health Res. 2013;23(5):700–10. 23. Varpio L, Ajjawi R, Monrouxe LV, O'Brien BC, Rees CE. Shedding the cobra effect: problematising thematic emergence, triangulation, saturation and member checking. Med Educ. 2017;51(1):40–50. 24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. 25. Clark J. How to peer review a qualitative manuscript peer review in health sciences. 2nd ed. London: BMJ Books; 2003. p. 219–35. 26. Queensland Health. Acute admission plan for children with eating disorders and associated physical compromise. Brisbane: Queensland Government; 27. Raveneau G, Feinstein R, Rosen LM, Fisher M. Attitudes and knowledge levels of nurses and residents caring for adolescents with an eating disorder. Int J Adolesc Med Health. 2014;26(1):131–6. 28. Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. 2014. 29. Linville D, Brown T, O’Neil M. Medical providers’ self perceived knowledge and skills for working with eating disorders: a national survey. Eat Disord. 2012;20(1):1. 30. HayP,Chinn D, Forbes D, MaddenS, NewtonR,Sugenor L,et al.Royal Australian and new Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014;48(11):977–1008. 31. Hay P, Darby A, Mond J. Knowledge and beliefs about bulimia nervosa and its treatment: a comparative study of three disciplines. J Clin Psychol Med Settings. 2007;14(1):59–68. 32. Reid M, Williams S, Hammersley R. Managing eating disorder patients in primary care in the UK: a qualitative study. Eat Disord. 2009;18(1):1–9. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Eating Disorders Springer Journals

Physicians’ perspectives on the treatment of patients with eating disorders in the acute setting

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Publisher
Springer Journals
Copyright
Copyright © 2019 by The Author(s).
Subject
Psychology; Psychology, general; Health Promotion and Disease Prevention; Psychiatry; Clinical Psychology
eISSN
2050-2974
DOI
10.1186/s40337-018-0231-1
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See Article on Publisher Site

Abstract

Background: Hospitalisation for an eating disorder is rare, however treatment in the acute medical setting can be a life-saving admission. While the multidisciplinary team delivers overall patient care, medical decisions are the responsibility of the treating physicians. Treatment decisions directly impact on patient care and outcomes. This study aimed to explore the considerations that influence the medical decisions of physicians when treating patients with eating disorders in the acute setting. Method: Semi-structured interviews were conducted with ten medical physicians who had previously treated eating disorders on a general medical unit in two Australian tertiary hospitals. An interview schedule, based on the literature and four relevant domains from the Consolidated Framework for Implementation Research, was developed. Interviews were audio recorded, transcribed verbatim and analyzed thematically. Coding and interim themes and sub- themes were developed by two dietitian researchers; these were further refined through researcher discussion and triangulation with two additional dietitian researchers. Results: Ten doctors were interviewed (3 consultants (1 adult general medical and 2 paediatricians: 13–16 years medical experience), 2 registrars (4–7 years experience), 1 resident (1 year experience), and 4 interns (< 1 year experience). Doctors described memorable patient cases, related to hospital stays over several weeks. Interviews ranged in length from 58 min to 91 min. Four themes (with five sub-themes) were developed: 1) navigating uncertainty (focusing on processes and goals and seeking information), 2) being “the good doctor” (doing the right thing), 3) seeing the big picture (depending on key players and considering short and long-term), and 4) involving family and patient. Conclusions: Non-specialist physicians described challenges in the treatment of eating disorders in the inpatient setting. They take a holistic approach that considers both short and longer-term goals, relying on specialist colleagues, the wider multidisciplinary team and sometimes family members to guide treatment decisions during admissions on general medical wards. Additional support, education and training centered on the key themes may increase physicians’ confidence and ability to make effective treatment decisions for this patient group. The results are relevant to all health professionals working in this field to better understand the priorities of medical physicians and to support them to achieve positive outcomes in the inpatient treatment of patients with eating disorders. Keywords: Eating disorders, Inpatients, Physicians, Patient care team, Qualitative, Medical, Decision making * Correspondence: dreidlin@bond.edu.au Faculty of Health Sciences and Medicine, Bond University, University Drive, Robina, QLD 4226, Australia Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 2 of 9 Plain English summary ensure optimal and consistent care of patients. In the Hospital treatment of eating disorders can be challenging United Kingdom, the National Institute for Health and for both patients and health care professionals. Physicians Clinical Excellence has recently developed new guidelines were of interest in this study, as they are responsible for for recognition and treatment of eating disorders, includ- the medical decisions made in the treatment of patients ing in the acute environment [13]. Clinical practice guide- with eating disorders during a hospital admission. Typic- lines from the American Psychiatric Association cover all ally, these patients are admitted to general medical wards, eating disorder diagnoses [10]; and in Australia, there are rather than specialist psychiatric wards. This research sets a range of similar clinical guidelines including those pro- out to understand physicians’ experiences when caring for duced by the Queensland Eating Disorder Outreach Ser- patients admitted to hospital for urgent, often life-saving, vice [14]. The aim of these guidelines is to provide health treatment. Ten physicians were interviewed about their professionals with a framework for daily medical measure- experiences with eating disorder patients. Key themes ments and behavioural management techniques for were developed to explain the underlying reasons for phy- patients [14]. However, the uptake of guidelines is known sicians’ decisions in the treatment of these patients, their to be inconsistent and dependent on a range of factors in- challenges and how they overcome these. Four themes cluding awareness and effective implementation [15]. (and five sub-themes) were 1) navigating uncertainty The experiences of nurses, dietitians, psychiatrists and (focusing on processes and goals and seeking informa- primary care physicians working with patients with eat- tion), 2) being “the good doctor” (doing the right thing), 3) ing disorders have previously been explored and assessed seeing the big picture (depending on key players and con- across quantitative and qualitative studies [16, 17]. How- sidering short and long-term), and 4) involving family and ever, hospital physicians – that is, those medical profes- patient. Physicians relied on family members, specialist sionals working in general medical rather than specialist colleagues, nurses, dietitians and other allied health psychiatric or mental health wards - have not previously professionals to ensure safe, evidence-based treatment been studied as a homogenous sample. Given the chal- that was focused on both short and longer-term recov- lenges highlighted across other health profession groups, ery goals. and the key role of physicians in acute medical wards in managing these patients, further insight into the reasons Background for treatment decisions in this patient group, including Eating disorders are characterized by ongoing abnormal those which may diverge from guidelines, is warranted and distorted eating habits or behaviours [1]. It is esti- [18]. For other health professionals, a better understand- mated that 30 million people in the USA, 1.25 million ing of the considerations informing the treatment deci- people in the United Kingdom and 1 million people in sions of physicians could support a more team focused Australia, are affected by an eating disorder [2–4]. Eat- approach to the care of patients with eating disorders ing disorders have the highest suicide and co-morbid admitted to non-specialist wards. This study aimed to mental illness rate of all mental health illnesses and are explore the considerations that influence the medical de- predominately managed in the community [5, 6]. Al- cisions of physicians when treating patients with eating though only a minority of people with an eating disorder disorders in the acute setting. are hospitalized [7], acute medical treatment is focused on medical stabilization, which can be lifesaving, and an Methods important part of an individual’s recovery. The most This was an interview study targeting physicians involved common diagnoses to require admission for medical in the treatment of eating disorders in two acute metro- stabilization are Anorexia Nervosa and other restrictive politan hospitals in South East Queensland, Australia. eating disorders [8]. Such treatment may include electro- Interviews were chosen as the most appropriate method lyte replacement, monitoring and correction of refeeding for exploring their experiences with eating disorder pa- syndrome, electrocardiograph monitoring, and oral or tients, in order to better understand the treatment deci- tube feeding [9, 10]. sions made by individual physicians, whilst providing a Caring for this patient group within the acute medical safe space to express potentially sensitive information setting is known to be challenging [11]. There is a need about their challenges and areas of uncertainty in treating for a cohesive approach encompassing medical and this patient group. An interview schedule (Additional file 1: psychological management, and to manage the patient’s Table S1) was developed by the research team to elicit ambivalence towards medical intervention [11]. A in-depth responses from the physicians to inform the multidisciplinary team approach and the use of guide- research aim. Questions were developed based on the lit- lines can facilitate treatment and overcome challenges erature and according to four relevant domains from the [12]. A range of guidelines for the treatment of people Consolidated Framework For Implementation Research with eating disorders across all settings are available to (CFIR): (1) characteristics of the individuals involved, (2) Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 3 of 9 process, (3) outer setting, and (4) intervention characteris- review guidelines [25] (Additional file 2:Table S2). Ethical tics [19]. To provide richness of data through real case vi- approval was obtained from the (Bond University Human) gnettes, physicians were asked to recall and describe two Research Ethics Committee prior to commencing recruit- patient cases they had previously treated: 1) a patient with ment, Ref: 015660. an eating disorder treated voluntarily and 2) another pa- tient treated involuntarily [20]. Prior to data collection, a Findings pilot interview was conducted with a medical intern, not Eleven physicians were recruited, ten were interviewed. eligible to participate, to refine the interview schedule. One physician provided written informed consent, but A convenience sample was sought, due to the known was deemed ineligible to participate due to having no ex- difficulties in recruitment of physicians to research stud- perience of treating eating disorders in an acute medical ies [21]. All eligible physicians who were willing and ward. Participating physicians had a range of medical available were invited to participate. Physicians from all experience; three attending physicians (one adult general experience levels currently working at the hospitals were medical and two pediatricians: 13–16 years medical ex- eligible, provided they had previously treated a patient perience), two fellows (4 to 7 years medical experience), with an eating disorder in an acute medical setting (such one junior resident (>1 year medical experience), and four as a general medical ward admission). Medical students, interns (<1 year medical experience). During the inter- nursing and allied health staff were excluded. One re- views, participants chose patient cases to describe in searcher recruited eligible physicians in a brief informa- detail, in response to the questions posed in the interview tion session at medical handover meetings and teaching schedule. The majority of physicians described experi- sessions at both hospitals. Recruitment snowballing was ences related to people with anorexia nervosa; one partici- used: once physicians had participated, they were then pant described their experience with a patient with asked to pass on the study information to potentially eli- bulimia nervosa. gible colleagues. Signed and informed consent was ob- Four themes (navigating uncertainty, being the good tained before each interview. doctor, seeing the big picture, involving patient and fam- Face-to-face semi-structured interviews were conducted ily) and five sub-themes (focusing on processes and goals, by one researcher in a private room at either hospital site. seeking information, depending on key players, consider- Interviews were audio recorded using a digital voice ing short and long term, and doing the right thing) were recorder and transcribed verbatim by one researcher and developed (Fig. 1). checked by a second researcher against the recordings for accuracy and to facilitate immersion in the data [22]. To Theme 1: navigating uncertainty ensure anonymity and confidentiality, potentially identifi- Within this theme, three sub-themes were developed: 1) able data disclosed during the interviews were removed focusing on processes and goals, 2) depending on key during transcription and replaced with pseudonyms, players and 3) seeking information. Physicians described including details of names, locations, and patient details. the treatment of patients with eating disorders as outside Inductive, line-by-line analysis of data was undertaken im- of their comfort zone. When describing cases, physicians mediately following transcription of each interview. The were more likely to express confidence about the objective interviewer recorded field notes after each interview to aid medical tests and interventions, but were less confident the analysis, and data collection ceased when there was communicating with the patient and behavioural manage- consensus among two of the researchers that the study’s ment. The physicians working in adult wards related this aim had been addressed. Thematic analysis followed a uncertainty to the relatively rare experience of treating pa- five-step process as recommended by Braun and Clarke: 1) tients with eating disorders. data familiarization, 2) initial coding, 3) theme development 4) theme review (whereby preliminary themes were applied “…they’re very few and far in between…So, it doesn’t to all codes until theoretical sufficiency was reached) [23] happen often for us.”– Physician #1. (male, attending and 5) theme defining and naming [24]. Microsoft Word physician, 14 years medical experience). was used to manage the data. Researcher triangulation en- sured trustworthiness during thematic analysis: coding and Whilst physicians working in pediatric wards did not preliminary themes were developed, discussed at length comment on the rarity of eating disorder patients, they still and agreed between two researchers, the selected exemplar described the challenges in navigating this uncertainty: quotes were then presented and discussed until there was agreement on the final themes and sub-themes amongst all “Sometimes I do wonder whether the way I approach four researchers (three of whom were dietitians, and the things or whether the way I say certain things, whether fourth of whom was a dietetic student). The manuscript that’s actually the best way or not.”– Physician #10 was prepared according to the RATS qualitative research (female, pediatrician, 13 years medical experience) Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 4 of 9 Fig. 1 Summary of themes and sub-themes and their interrelationships Physicians, from adult and pediatric units, described unsafe medical status was the physicians’ main priority their uncertainty about management of eating disorders as in treatment: due to eating disorders not being “black and white” -the decisions they faced, in particular behavioural manage- “…obviously for a patient that’sinthe acute ment decisions, were subjective. Physicians described how setting, you have to be worried about refeeding they would navigate this uncertainty by seeking informa- syndrome. And you wanna do that safely.”– tion: for example, referring to a guideline or protocol, the Physician #8 (female, intern, less than one year evidenced-based literature, and other health professionals medical experience). from the multidisciplinary team whom they identified were key players in effective treatment, including specialist Physicians described their responsibility to do the right colleagues in the liaison psychiatric services, dietitians, thing by the patient, the family and other treating health psychologists and nurses. professionals. This included meeting the expectations of the patient and the family, and answering complex ques- “…talking to my other consultant colleagues, tions proposed by family: especially with regard to approaching family and conflicts between medical staff and family “It’s difficult because they have so many straight, and how they’ve managed them, influences in closed questions that they want answers to that never a way cause they’ve done it more often than have straight answers…But, I feel like we don’t always me.”– Physician #1 (male, attending physician, tell them what they expect to hear…”- Physician #2 14 years medical experience – referring to (male, junior resident, 1 year medical experience). liaison psychiatric services colleagues in the hospital). However, there was one deviant case, a general med- ical attending physician, who described how he would only focus on what he believed was right for the patient, Theme 2: being “the good doctor” even if this meant ignoring the family’s demands and Within this theme there were two sub-themes: 1) doing protests, which in some cases was difficult to do: the right thing and 2) seeking information. Physicians described that fulfilling “the good doctor” role was an in- “…the main thing that makes me determine what to ternal drive to do what is best for their patient and pa- do with a patient is what’s going to be best for them tient safety. The elimination of the cause of the patient’s and not what’s best for the family, or for anyone else.” Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 5 of 9 – Physician #1. (male, attending physician, 14 years followed up with long-term care then the patient would medical experience). not recover. To ensure long-term care was applied one physician described how this influenced her discharge Physicians described that being “a good doctor” also planning for patients: included being a life-long learner. Treatment of eating disorders was described as being only ‘briefly touched “…my goals are generally short-term goals, so I wanna on’ in medical school, thus physicians often identified make them safe enough. My long-term goals with these eating disorder issues as something of a gap in their patients is to provide them with a plan and then a knowledge and experience. During medical school, phy- support network which would usually include an sicians described that the importance of seeking infor- outpatient psychologist and dietitian.” – Physician #5 mation from credible sources to guide practice was (female, fellow, 7 years medical experience). instilled in them: Re-admissions were expressed as one of the many “...if, you know, we’re ordering an investigation or challenges to treating this patient group because physi- something and I don’t really understand why, if I don’t cians then felt that their own previous treatment at- get the opportunity to ask someone more senior then I tempts had failed. One physician felt that the reason for generally like to sort of look into that myself…” – re-admissions was because time between discharge and Physician #6 (intern, female, <1 year experience). follow-up appointments in the community was too long, and many patients were being re-admitted to hospital in that time: Theme 3: seeing the big picture Within this theme were two sub-themes, 1) depending “So, you discharge someone, cool, we’ve got you to a on key players and 2) considering short and long-term. good BMI. They start to go yeah; okay I think we In this theme, physicians spoke of the importance of might win this one… your outpatient appointment’sin having an overview of all aspects of care as vital in the two weeks or three weeks with psychology... In that two patient’s treatment. Physicians described that from ad- weeks they’re back in again.”– Physician #2. (male, mission, through to transfer (for example to an inpatient junior resident, 1 year medical experience). psychiatric unit within the hospital) and discharge, con- sidering the patient’s condition from multiple angles, not just a single variable such as body mass index, assisted Theme 4: involving family and patient in their decision-making: This theme encompassed two components: firstly, the in- volvement of family in treatment and decision-making. “I don’t think [admission] is always just a number... Physicians working on pediatric wards described that in- it’s always a picture of things.”– Physician #2. (male, volving the patient’s parents was mandatory. Physicians junior resident, 1 year medical experience). treating adults described that the family was only involved in treatment with the patient’s consent. However, both de- Physicians described this overarching approach included scribed that family could be a ‘double-edged sword’.On short and long-term goals, but also included collaboration one-hand family was identified as a useful tool in treat- with a range of health professionals from the multidiscip- ment, such as admitting the patient to hospital, and their linary team. Physicians universally agreed that they could role in family-based therapies. When family were per- not treat a patient with an eating disorder alone. For their ceived as supportive and able to contribute to treatment, patients with eating disorders they made referrals to physicians readily involved them: specialists to assist with treatment, including a psychiatrist and dietitian. The physicians demonstrated respect to- “…they’re going to be the ones to keep an eye out for wards the other disciplines, so long as these other health warning signs. So, it’s important to involve them in professionals fulfilled their role in treatment. their care as well.” – Physician #5 (female, fellow, 7 The sub-theme “short and long-term” encompassed all years medical experience). aspects of treatment. Physicians detailed that their pa- tients typically spend several weeks on a general medical On the other hand, physicians described that family ward, reflecting the longer length of stay for this patient could also be detrimental to treatment. Physicians empa- group (a mean of almost 20 days compared to 2.9 days thized with the family, and perceived the family had the for other admissions in Australia) [7]. They described patient’s “best interest at heart” yet were not always able their role in medical stabilization of the patient as only a to express this constructively. Physicians described expe- temporary fix, acknowledging that if discharge was not riences of family members who were hostile towards the Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 6 of 9 diagnosis and treatment plans, but at times seemed to care physicians and to support them in their treatment of begrudgingly welcome them into treatment decisions. patients with eating disorders. The physicians in this study identified patients with eat- “…So I think it’s…more important… than your ing disorders as unusual, describing the relative rarity of regular run of the mill medical patient to be admissions as a key contributor to their uncertainty when a bit more careful about the family…They can making treatment decisions. This perception of ‘rarity’ be really supportive and really helpful. But at appears to be real, with the majority of treatment con- the sametimetheycan be quite detrimentaltoo.” – ducted in outpatient and community settings rather than Physician #3. (male, intern, less than one year inpatient admissions [7]. The observation that people with medical experience). eating disorders present for treatment in small numbers is consistent with results from a qualitative study in the UK, The second component to this theme was involving the which explored the experiences of a range of health pro- patient. How the physicians involved the patient in treat- fessionals providing inpatient and outpatient care for ment was highly variable. Physicians described the pa- people with eating disorders. This study also found that tient’s capacity to make their own treatment decisions as participants working on a general medical ward felt they more likely if patient decisions aligned with those of the were lacking the experience to effectively treat people with doctor. From the physicians’ perspective patients were eating disorders due to low admission rates [6]. Similarly, generally expected to comply with treatment. However, in the same researchers interviewed general practitioners the case of eating disorders, the physicians also described who described this patient group as small in number, but anticipation of “non-compliance”. They described treat- high in complexity [6]. ment of patients with eating disorders as easier if the pa- The finding that physicians rely on practice guidelines tient had insight into their illness, where insight referred to manage their uncertainty when making treatment to a patient’s perception and knowledge of their mental decisions is perhaps not surprising. A guideline for the health illness. The physicians described the patient’s inpatient medical management of a patient with an eat- insight, or lack of insight, would contribute to the uncer- ing disorder is available to physicians working in the tainty and challenges of treatment: adult and pediatric wards within the health district studied [14, 26] although it was clear during the inter- “…it can be challenging with the patients who views that different physicians used different guidelines, don’t have the insight into their illness, because andsomewereunaware of theguideline.Somedoctors they don’t necessarily want your help, that can be relied on more senior colleagues and/or other health a challenge.”– Physician #4 (male, intern, less than professionals to guide their treatment decisions, rather than year medical experience). the guideline. Protocols and guidelines aim to support health professionals in facilitating treatment to overcome potential challenges with eating disorders [14]. They have Discussion been identified as useful for doctors and other health pro- This study set out to explore the considerations of phy- fessionals to overcome challenges and barriers, such as sicians in their treatment of patients with eating disor- communication and the complexity of individualized man- ders, focused on those that influence medical decisions agement in patients with eating disorders in the acute med- during acute hospital admissions. Key findings were ical setting [27]. Additionally, it has been suggested that the captured in the four themes and five subthemes devel- less experienced the health professional is in treating a con- oped, which highlighted the uncertainties in treatment dition, the greater the reliance on guidelines in treatment decisions, beneficence of physicians in wanting to do [15]. However, physicians in the present study expressed a what was best for their patients, with an understanding that reliance on guidelines regardless of their experience level. this requires the physicians to think beyond the immediate The commitment to lifelong learning by physicians in acute problems. Physicians identified that support in the this study reflect professional expectations of continuing form of treatment guidelines and evidence, along with the professional development and evidence-based medicine advice of more experienced colleagues and the wider team [28, 29]. Knowledge of eating disorders and of appropri- were critical to their treatment decisions. They described ate acute medical treatment is vital for physicians to key challenges they faced due to the relative rarity of eating effectively manage patients with eating disorders. Re- disorder admissions, the need to tailor the treatment ac- search has shown that insufficient knowledge of eating cording to the patient and their level of insight, and the key disorders can result in lowered confidence in treating role of family as potential enablers of successful treatment. patients, which is consistent with our findings [18, 29]. These findings are relevant to all health professionals work- Opportunities for professional development in effective ing in this field to better understand the priorities of acute treatment and relevant guidelines for this patient group Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 7 of 9 may go some way to meeting the needs of physicians in that the family played in effective treatment. Socially ac- the acute setting, perhaps in an interdisciplinary setting to ceptable behaviour for a patient is usually to seek and encourage sharing and understanding within the multidis- accept help from a health professional [33]. Eating dis- ciplinary team. order patients typically go against this norm - poor The beneficence of physicians in this study was insight, ambivalence and refusal of professional help are highlighted by their motivation to be the “good doc- key characteristics of patients with eating disorders, in tor”. This likely reflects the altruistic nature of those particular those with Anorexia Nervosa [30]. Other that choose medicine as a career, along with the pro- health professionals have noted the propensity for pa- fessional and ethical conduct codes imbued in medical tients to refuse treatment options as complicating treat- school training and upheld by physicians in their prac- ment decisions in eating disorder care, and described tice [28]. The responsibility to do what is right by the the difficulty of having to treat someone who refuses patient, and to meet expectations placed on the physi- care [34]. cians by both patient and parent (family) has been pre- Involving family as a partner in discussions and treat- viously described. Health professionals interviewed in ment of a patient is the crux of patient- and family- a UK study expressed intentions to do what is best by centered care [35]. Family members are also a valuable their eating disorder patients, but noted uncertainty source of information and play an important part in the about the correct course of action for their individual long-term care of the patient. The hesitation to involve patients [6]. The influence of perceived patient and family was also previously described by health profes- family expectations of the physician during inpatient sionals who worked with children and adolescents with treatment was also reported in an interview study of eating disorders in a range of settings. Participants in health professionals working in an adult eating dis- the current study found the decision to involve family order inpatient service, where participants felt it was as more difficult than the objective medical decisions difficult to meet high expectations of care and the re- [36]. Support for physicians to optimize communica- covery process [11]. tion with patients and family, possibly through training The physicians in this study were grateful for the input or professional mentoring, may result in more inclusive of other health professionals including mental health spe- treatment decisions that support acute recovery and ef- cialists to inform their treatment decisions, and supports fective discharge. practice guidelines and literature which advocate multidis- ciplinary team working as the most effective approach to Strengths and limitations treatment [17, 30]. Key members of the multidisciplinary A key strength of this study was the successful recruitment team for eating disorders include dietitians, psychologists of physicians across two hospitals in the same health dis- and medical practitioners [14]. Although each individual trict. Physicians are known to be a difficult population to specialist has a crucial role in eating disorder treatment, recruit for research due to many reasons, including de- the ineffectiveness of isolated treatment has been noted manding schedules, which occurred in this study [37]. The [13, 31]. These findings should strengthen the role of decision to only include general medical physicians meant health professionals working with physicians during acute an initial, smaller pool to recruit from, but also provided a care admissions. unique homogenous participant group who represent key The physicians in this study described readmissions decision makers in the medical treatment of eating disorder as setbacks, and attributed these in part to untimely fol- patients admitted to hospital. The information gathered low up of patients after discharge. Patients with eating from physicians who participated in this study provided disorders have high rates of relapse and readmission a range of experience and insight into the research [11]. Delayed follow-up has also been described as a prob- question. With this smaller sample size, theoretical lem in the primary care setting, where general practitioners sufficiency (whereby new data was able to be accommo- described lengthy referral waiting lists [32]. Ensuring timely dated within the developed themes without further modifi- and intense follow-up treatment has been identified as one cations) was achieved [23], although it is possible that with method of decreasing rates of relapse and readmissions a larger sample size, a greater number or modified themes [30]; other suggestions include training, primary care refer- may have been developed. However, interviews were ad- rals and continuity of care as key components of effective equate in length, about 1 h each – remarkable considering careintheprimarycaresetting [6]. Our findings indicate the busy schedules of the participants - and produced rich physicians’ frustration and erosion of confidence in the data into the experiences and influences of the physicians treatment of eating disorder patients as a result of this re- involved. The patient cases described by physicians were admission cycle. chosen by them, and it is possible that the cases described The complexity of care of people with eating disorders didnot reflectthe full gamutofadmissionstoageneral extended to the patient and their insights, and the role medical ward such as short admissions for electrolyte Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 8 of 9 correction only. In addition, the descriptions were limited Acknowledgements The authors would like to acknowledge and thank the physicians who contributed to details that the doctor could recall during the interview, their time and professional experiences to this study, and thank all those involved in and in some instances, these may have been unclear or recruitment. misremembered. For example, some physicians could not Funding recall whether treatment was involuntary or voluntary, but There was no financial aid or funding for this project. nevertheless chose a case because they were comfortable to discuss it in detail. Analysis was conducted by researchers Availability of data and materials The datasets generated during and/or analysed during the current study are who were all dietitians or a student dietitian, and we not publicly available due to participants in this study not providing explicit acknowledge that this almost certainly influenced the consent for transcripts to be shared but are available from the corresponding final themes developed and presented here; analysis by author on reasonable request. Requests for data to be made available will be referred to the institution review board for consideration. researchers with a more diverse professional back- ground may have resulted in different interpretations of Authors’ contributions the data. The analysis adds insight into the thoughts All authors contributed to the research conception, study design and ethical approvals. ARD undertook recruitment and data collection. All authors contributed and concerns of treating physicians, we believe for the to data analysis and interpretation, as well as manuscript preparation. ARD wrote first time. the first draft of the manuscript. All authors critically reviewed the manuscript and The study findings highlight future opportunities for approved the final version for submission. research and service improvements in this area. They Authors’ information emphasize the need to build physicians’ (and medical stu- Three of the authors, SB, LD and DPR currently work or have previously dents’) knowledge and confidence in working with pa- worked in acute hospital settings with eating disorder patients. DPR is an Accredited Practising Dietitian (Australia) and a Registered Dietitian tients with eating disorders. Training for physicians, and (UK), SB and LD are Accredited Practising Dietitians (Australia), and ARD perhaps also allied health colleagues supporting them, that was a student dietitian in a Master of Nutrition and Dietetic Practice is focused on awareness of existing resources, including program during the study. guidelines and protocols for inpatient treatment, and Ethics approval and consent to participate skills to manage the challenges of working with patients Approval was gained from (Bond University Human) Research Ethics Committee, with eating disorders, their families and colleagues is Ref: 015660. All participants were provided with a Participant Information Sheet and Consent Form and signed prior to commencement of interviews. warranted. Conducting a similar study with other health professionals involved in the treatment of eating Consent for publication disorders in the acute setting, such as nurses, dietitians Not applicable. and psychologists, could add to the more effective im- Competing interests plementation of guidelines within acute medical wards. The authors declare that they have no competing interests. Conclusions Publisher’sNote The physicians viewed the multidisciplinary team ap- Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. proach as vital to the treatment of eating disorders in an acute setting, which should instill confidence in other Author details health professionals working in this clinical area. Further, Faculty of Health Sciences and Medicine, Bond University, University Drive, Robina, QLD 4226, Australia. Gold Coast Hospital and Health Services, their awareness of the physicians’ experiences, including Southport, Australia. an understanding of the challenges physicians face with this patient group, should ensure other members of the Received: 19 August 2018 Accepted: 5 December 2018 multidisciplinary team can better support the medical team to more effectively treat them in the acute setting. References The results are relevant to all health professionals work- 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed; 2013. ing in this field to better understand the priorities of 2. Butterfly Foundation for Eating Disorders. Investing in need: cost-effective acute care physicians and to support them in their treat- interventions for eating disorders. Sydney: The Butterfly Foundation; 2015. ment of patients with eating disorders. Such awareness 3. National Association of Anorexia Nervosa and Associated Disorders. Eating disorder Statistics 2017. Available from: https://anad.org/education-and- is likely to improve team dynamics as well as outcomes awareness/about-eating-disorders/eating-disorders-statistics/. for this patient group. 4. Beat Eating Disorders. Statistics for Journalists: How many people in the UK have an eating disorder? n.d. Available from: https://www. beateatingdisorders.org.uk/media-centre/eating-disorder-statistics. Additional files 5. Hay PJ, Claudino AM, Touyz S, Abd Elbaky G. Individual psychological therapy in the outpatient treatment of adults with anorexia nervosa. Additional file 1: Table S1. Interview guide with rationale for inclusion. Cochrane Database Syst Rev. 2015;(7):Cd003909. https://doi.org/10.1002/ (DOCX 31 kb) 14651858.CD003909.pub2. 6. Reid M, Williams S, Burr J. Perspectives on eating disorders and service Additional file 2: Table S2. Qualitative research review guidelines – provision: a qualitative study of healthcare professionals. Eur Eat Disord Rev. RATS. (DOCX 23 kb) 2010;18(5):390–8. Davidson et al. Journal of Eating Disorders (2019) 7:1 Page 9 of 9 7. Butterfly Foundation for Eating Disorders. Paying the price: the economic 33. Bradby H. Medicine, health and society: a critical sociology. Los Angeles: and social impact of eating disorders in Australia. Sydney: The Butterfly SAGE; 2012. Foundation; 2012. 34. Walker S, Lloyd C. Barriers and attitudes health professionals working in 8. Health and Social Care Information Centre. Provisional monthly topic of eating disorders experience. Int J Ther Rehabil. 2011;18(7):383–90. interest: Eating disorders. In: Hospital Episode Statistics (HES). Leeds: NHS 35. Gallo KP, Hill LC, Hoagwood KE, Olin S-cS. A narrative synthesis of the Digital, United Kingdom National Health Service; 2016. components of and evidence for patient- and family-centered care. Clin 9. Gaudiani JL, Sabel AL, Mascolo M, Mehler PS. Severe anorexia nervosa: Pediatr. 2016;55(4):333–46. outcomes from a medical stabilization unit. Int J Eat Disord. 2012;45(1): 36. Lafrance Robinson A, Kosmerly S. The influence of clinician emotion on 85–92. decisions in child and adolescent eating disorder treatment: a survey of self and others. Eat Disord. 2015;23(2):163–76. 10. Yager J, Devlin MJ, Halmi KA, Herzog DB, Mitchell IIIJE, Powers P, et al. 37. Asch S, Connor SE, Hamilton EG, Fox SA. Problems in recruiting community- Practice guideline for the treatment of patients with eating disorders third based physicians for health services research. J Gen Intern Med. 2000;15(8): edition. Am J Psychiatry. 2006;163(7):1-128. 591–9. 11. Davey A, Arcelus J, Munir F. Work demands, social support, and job satisfaction in eating disorder inpatient settings: a qualitative study. Int J Ment Health Nurs. 2014;23(1):60–8. 12. Warren CS, Crowley ME, Olivardia R, Schoen A. Treating patients with eating disorders: an examination of treatment Providers’ experiences. Eat Disord. 2008;17(1):27–45. 13. National Institute for Health and Care Excellence. Eating disorders: recognition and treatment. London: NICE; 2017. 14. Royal Brisbane and Women’s Hospital. A guide to admission and inpatient treatment for people with eating disorders in Queensland. Brisbane: Metro North Hospital and Health Service; 2014. 15. Francke AL, Smit MC, de Veer AJ, Mistiaen P. Factors influencing the implementation of clinical guidelines for health care professionals: a systematic meta-review. BMC Med Inform Decis Mak. 2008;8:38. 16. Banas DA, Redfern R, Wanjiku S, Lazebnik R, Rome ES. Eating disorder training and attitudes among primary care residents. Clin Pediatr. 2013;52(4):355–61. 17. Seah XY, Tham XC, Kamaruzaman NR, Yobas P. Knowledge, attitudes and challenges of healthcare professionals managing people with eating disorders: a literature review. Arch Psychiatr Nurs. 2016;31(1):125-36. 18. Currin L, Waller G, Schmidt U. Primary care physicians’ knowledge of and attitudes toward the eating disorders: do they affect clinical actions? Int J Eat Disord. 2009;42(5):453–8. 19. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. 20. Douzenis A, Michopoulos I. Involuntary admission: the case of anorexia nervosa. Int J Law Psychiatry. 2015;39:31–5. 21. VanGeest JB, Johnson TP, Welch VL. Methodologies for improving response rates in surveys of physicians: a systematic review. Eval Health Prof. 2007; 30(4):303–21. 22. Hennink M, Weber MB. Quality issues of court reporters and transcriptionists for qualitative research. Qual Health Res. 2013;23(5):700–10. 23. Varpio L, Ajjawi R, Monrouxe LV, O'Brien BC, Rees CE. Shedding the cobra effect: problematising thematic emergence, triangulation, saturation and member checking. Med Educ. 2017;51(1):40–50. 24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. 25. Clark J. How to peer review a qualitative manuscript peer review in health sciences. 2nd ed. London: BMJ Books; 2003. p. 219–35. 26. Queensland Health. Acute admission plan for children with eating disorders and associated physical compromise. Brisbane: Queensland Government; 27. Raveneau G, Feinstein R, Rosen LM, Fisher M. Attitudes and knowledge levels of nurses and residents caring for adolescents with an eating disorder. Int J Adolesc Med Health. 2014;26(1):131–6. 28. Medical Board of Australia. Good medical practice: a code of conduct for doctors in Australia. 2014. 29. Linville D, Brown T, O’Neil M. Medical providers’ self perceived knowledge and skills for working with eating disorders: a national survey. Eat Disord. 2012;20(1):1. 30. HayP,Chinn D, Forbes D, MaddenS, NewtonR,Sugenor L,et al.Royal Australian and new Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Aust N Z J Psychiatry. 2014;48(11):977–1008. 31. Hay P, Darby A, Mond J. Knowledge and beliefs about bulimia nervosa and its treatment: a comparative study of three disciplines. J Clin Psychol Med Settings. 2007;14(1):59–68. 32. Reid M, Williams S, Hammersley R. Managing eating disorder patients in primary care in the UK: a qualitative study. Eat Disord. 2009;18(1):1–9.

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Journal of Eating DisordersSpringer Journals

Published: Jan 10, 2019

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