Background Eating disorders affect 1%–4% of the population and they are associated with an increased rate of mortality and multimorbidity. Following the avoidable deaths of three people the parliamentary ombudsman called for a review of training for all junior doctors to improve patient safety.
Objective To review the teaching and assessment relating to eating disorders at all levels of medical training in the UK.
Method We surveyed all the UK medical schools about their curricula, teaching and examinations related to eating disorders in 2017. Furthermore, we reviewed curricula and requirements for annual progression (Annual Review of Competence Progression (ARCP)) for all relevant postgraduate training programmes, including foundation training, general practice and 33 specialties.
Main outcome measures Inclusion of eating disorders in curricula, time dedicated to teaching, assessment methods and ARCP requirements.
Results The medical school response rate was 93%. The total number of hours spent on eating disorder teaching in medical schools is <2 hours. Postgraduate training adds little more, with the exception of child and adolescent psychiatry. The majority of doctors are never assessed on their knowledge of eating disorders during their entire training, and only a few medical students and trainees have the opportunity to choose a specialist placement to develop their clinical skills.
Conclusions Eating disorder teaching is minimal during the 10–16 years of undergraduate and postgraduate medical training in the UK. Given the risk of mortality and multimorbidity associated with these disorders, this needs to be urgently reviewed to improve patient safety.
- eating disorders
- primary care
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The UK parliamentary ombudsman’s investigation into the avoidable deaths of three people with eating disorders was published in December 2017.1 Sadly, the case stories were similar to the ones described in the ’Management of Really Sick Patients with Anorexia Nervosa' guidelines (MARSIPAN)2: the patients had been seen by a number of healthcare professionals, including medical doctors working in a variety of specialties, before their death, but the recognition and management of risk was inadequate. The first two recommendations of the ombudsman’s report are:
The General Medical Council (GMC) should conduct a review of training for all junior doctors in eating disorders to improve understanding of these complex mental health conditions.
Health Education England (HEE) should review how its current education and training can address the gaps in provision of eating disorder specialists.
Patient safety is at the centre of the GMC standards for undergraduate and postgraduate education and training.3 The GMC specifies core generic skills, knowledge and attributes that doctors must acquire during their medical education. These include nutrition, psychological and social factors relating to health and disease at the same level of importance as the other, more traditionally taught subjects, such as prescribing.
So, why is it that, although the MARSIPAN project started about 10 years ago with the intention to improve patient safety in severe eating disorders, avoidable deaths continue to happen? The ombudsman highlighted five areas that need to change, and in this paper, we would like to focus on the training issues.
According to Beat, the leading eating disorder charity, 1.25 million people suffer from eating disorders in the UK (https://www.beateatingdisorders.org.uk/media-centre/eating-disorder-statistics). This figure is likely to be conservative, as epidemiological research suggests 1%–4% prevalence rates in high-income countries.4 5 All eating disorders have an increased rate of mortality, with anorexia nervosa having the highest rate among psychiatric disorders.6 7 Physical or psychiatric comorbidities are common and they increase the risk.6 This is in stark contrast with the common misperception that eating disorders are trivial and self-imposed problems.8 The physical complications of eating disorders are partially to malnutrition, including acute metabolic or electrolyte disturbances, gastrointestinal or cardiac complications,9 10 fertility and perinatal complications,11 bone metabolic12 or endocrine13 problems, growth and developmental delay in children. In addition, certain physical illnesses are associated with eating disorders. These include various autoimmune disorders14 and diabetes.15 Furthermore, approximately 40%–70% of patients have psychiatric comorbidity, with increased risk of self-harm and suicide.5 6 16 Patients with comorbid alcohol use are at particularly high risk of mortality.
Eating disorder psychiatry is not a GMC recognised subspecialty, and according to the most recent Royal College of Psychiatrists (RCPsych) census, the number of consultants working in the UK is <100 (http://www.rcpsych.ac.uk/workinpsychiatry/workforce/census.aspx). Clearly, the number of doctors specialising in this area is insufficient to meet the needs of the patient population, particularly in emergencies, and people with eating disorders are often first seen, with severe complications, by other doctors, either in primary care, or in acute hospitals.
Research suggests that the majority of non-specialists do not feel confident in helping patients with eating disorders,17 leading to delays in treatment or inappropriate management, which is consistent with the ombudsman’s findings. The most likely reason for this is limited education and training in eating disorders. Previous studies have highlighted the need for more training among various groups of doctors, both in the UK and internationally.17–22 However, there is no systematic data on the total amount of eating disorders training throughout the entirety of a medical doctor’s career in the UK.
In this paper, our objective was to establish the extent of current teaching and assessment relating to eating disorders at undergraduate and postgraduate levels in the UK, with the aim of making recommendations for improvement.
Design: we carried out a review of eating disorder teaching at all levels of medical training, from undergraduate to postgraduate, in the UK in 2017. The structure of medical education in the UK is outlined in figure 1.
We contacted all 33 UK universities awarding primary medical qualifications under the Freedom of Information Act 2000 and the Freedom of Information (Scotland) Act 2002 (FOI). We asked whether eating disorders were included in their undergraduate curriculum, how much time was dedicated to the topic and whether the course delivered the following aspects:
Physical complications, psychiatric aspects, risk recognition and management of eating disorders, including compulsory treatment;
Clinical experience: opportunities for patient contact, including clinical attachments, and special interest modules;
Assessments: number of questions relating to eating disorders in the final written and clinical examinations, as well as whether there is a specific requirement to assess clinical skills in managing patients with eating disorders before completion of training.
All doctors in the UK need to complete foundation training after their primary medical qualification. Foundation training is organised by HEE in individual deaneries and Local Education Training Boards (LETB) following a national curriculum. There is no examination for foundation doctors. Instead, the career progression is competency based and is demonstrated by a set number of workplace-based assessments (WPBA) and professional tasks that need to be met for the Annual Review of Competence Progression (ARCP). We searched the Foundation Programme Curriculum and ARCP requirements.23
There are 65 medical specialties and 36 subspecialties in the UK. Each of them has their own curricula and examinations developed by the relevant Royal Colleges or Faculties and all are approved by the GMC. Teaching is delivered by deaneries and LETB, and it consists of didactic teaching and rotational clinical placements. Progression in training is determined by ARCP using a combination of portfolio evidence of competencies and success in professional exams set by the Royal Colleges.
The Royal Colleges are charities, so the Freedom of Information Act does not apply to them. We reviewed all core and relevant GMC recognised subspecialty curricula (http://www.gmc-uk.org/education/approved_curricula_systems.asp) and exam syllabi on the relevant websites for the following keywords: eating disorders, anorexia nervosa, bulimia nervosa, binge eating disorder and nutrition. In addition, we contacted all Royal Colleges asking them about their assessment of the topic as for the medical schools. We included the following Royal Colleges and specialties, which had direct relevance to the management of this patient population:
Royal College of Physicians (RCP): MRCP exam, and subspecialty curricula for gastroenterology, general internal medicine, metabolic medicine, cardiology, acute internal medicine, sport and exercise medicine;
Royal College of General Practitioners (RCGP): RCGP curriculum;
Royal College of Emergency Medicine;
Royal College of Paediatrics and Child Health: general paediatrics, paediatric diabetes and endocrinology, paediatric mental health;
Royal College of Obstetrics and Gynecology: reproductive medicine, maternal and fetal medicine;
Royal College of Surgeons: general surgery and plastic surgery;
Faculty of Public Health;
Royal College of Psychiatrists (RCPsych): MRCPsych, general adult psychiatry, child and adolescent psychiatry, forensic psychiatry, old age psychiatry, psychiatry of learning disability, medical psychotherapy, liaison psychiatry, rehabilitation psychiatry and substance misuse psychiatry.
We also searched the nationally available specialist eating disorder training posts on the RCPsych website: https://www.rcpsych.ac.uk/workinpsychiatry/faculties/eatingdisorders/edfacultytraining.aspx#posts
Data were analysed using descriptive statistics by SPSS V.22.
All medical schools in the UK were contacted under FOI. The response rate from medical schools was 93%. We excluded two universities from the analysis: St Andrews, as they only offer preclinical teaching, and Lancaster, which had not started clinical teaching at the time of data collection.
Twenty-four medical schools include eating disorders in their undergraduate curriculum, whereas six do not (table 1). Universities using problem-based learning (PBL) or integrated curricula found it difficult to provide specific details on eating disorders teaching.
Seventy-one per cent offered theoretical teaching on the topic (including four using PBL) and 45% clinical skills teaching. Mean time dedicated to eating disorder teaching was: 1.2±1.2 (0–4) hours theoretical and 0.6±0.9 (0–3) hours clinical skills teaching. Some universities provide online training material instead.
Clinical contact was also limited: only six universities had student placements in specialist CAMHS eating disorders and seven in adult services. The numbers of these placements were limited to 6–12 students/university in a year. Six universities offered optional specialist modules in eating disorders for interested students.
With regard to questions about assessment, five universities refused to disclose the number of eating disorder questions in their final examination, owing to concerns about commercial interests, or the possibility of the exam being compromised. Two universities had no finals. Fifty per cent of responders did not include questions on eating disorders in final undergraduate medical exams. Only two universities included a specific requirement to assess clinical skills in emergency department (ED) before graduation.
Important competencies relevant to eating disorders are included in the foundation curriculum:
Routinely assesses patients’ basic nutritional requirements;
Performs basic nutritional screen including assessing growth in children
Works with other healthcare professionals to address nutritional needs and communicate these during care planning;
Recognises eating disorders, seeks senior input and refers to local specialist service;
Formulates a plan for investigation and management of weight loss or weight gain.
The delivery of foundation training is arranged by deaneries and LETB. There is no systematic information available on how many offer eating disorder teaching or clinical experience for foundation doctors. There is no requirement to demonstrate clinical competencies in WPBA as part of ARCP. There are only a few eating disorder placements that are available for foundation doctors in the UK.
Core training and specialist training
We had no response from the Royal Colleges to our request about examinations. However, we reviewed all curricula, exam syllabi and ARCP requirements, which are publicly available. Table 2 shows that the majority of specialties do not include eating disorders in their curricula. As curricula drive clinical placements and assessment, it can be said with some certainty that most medical specialties have no further training or assessment on eating disorders. On the other hand, most include nutrition, which is important for managing physical complications. The only exception is psychiatric training, which includes eating disorders, but not nutrition. General practitioners (GPs), paediatricians and surgeons (higher training only) include both nutrition and eating disorders in their curricula.
However, eating disorders are only mentioned in one word or one sentence in the majority of these usually large documents of hundreds of pages (table 3), so it is highly likely that the proportion of time spent on training and the examination structure reflects this. There are no ARCP requirements for these specialties relating to eating disorders.
Teaching and clinical placements for core and specialist training are organised by deaneries and LETBs.
In postgraduate psychiatry training, there is no specific requirement for psychiatrists to demonstrate clinical competencies in ED as part of ARCP, except for child and adolescent psychiatry. Several of the subspecialty curricula in psychiatry, such as substance misuse or medical psychotherapy, do not include clinical competencies in eating disorders. ARCP requirements do not specify the range of psychiatric conditions that need to be covered before completion of training, hence the majority of trainees do not have a WPBA in eating disorders.
According to the RCPsych Eating Disorder Faculty, there are only 17 core training posts and 18 higher specialist training posts available in the UK.
The majority of doctors in the UK receive <2 hours of teaching on eating disorders during their entire medical education, which takes 10–16 years. They usually receive this in medical school. Even at that level, there are inconsistencies: 20% of medical schools do not include eating disorders in their teaching. While both the national undergraduate nutrition curriculum24 and the Royal College of Psychiatrists’ undergraduate curriculum include the topic,25 these are only advisory. Opportunities for specialist clinical experience are limited to <1% of medical students nationally.
Assessment of theoretical and clinical knowledge of eating disorders is minimal during the entire medical training structure. Given that assessment drives learning, it is not surprising that most doctors, including most psychiatrists, do not feel confident managing this patient population.17 22 The limited training and assessment reinforce the unhelpful myths26 that eating disorders are a niche area irrelevant to medical education.
Foundation competencies include making an assessment of the patient’s state of nutrition, and recognition of eating disorders. However, the ARCP requirements do not specify relevant competencies. Only a few specialist training posts are available.
Core and higher specialist training includes either nutrition or eating disorders as individual subject areas within their curricula in relevant specialties, reflecting the historical divide between physical and mental health. This divide is unhelpful for patients, who often present with both physical and psychiatric risks and comorbidities. Clearly, safe management must address both. Even in those specialties that include both, the detail regarding eating disorders is minimal. For example, no postgraduate curriculum mentions binge eating disorder, although this is the most common presentation and is associated with a range of physical and mental health complications, such as diabetes, obesity, depression and suicide.4 27
The lack of training of public health medicine may explain why the recent guidelines by Public Health England regarding healthy eating do not consider the needs of people with eating disorders, which has caused concerns by specialists and patient support groups (https://www.beateatingdisorders.org.uk/news-research/change4lifes-100-calorie-campaign).
Among existing GMC recognised psychiatric specialties, only child and adolescent psychiatry includes in its curriculum a comprehensive list of competencies related to eating disorders, which must be achieved by all higher specialist trainees before completion of training. The others either include limited eating disorder competencies or none at all, and there is no specific requirement for completion of specialist training, except for child and adolescent psychiatry. This is surprising, as there are more adult patients, and they have a high rate of comorbid psychiatric disorders.5 The number of specialist eating disorder psychiatry training placements is limited; therefore only a small proportion of psychiatry trainees have an opportunity to develop expertise with this patient population during the 6–7 years of their postgraduate training. Yet, other mental disorders with similar prevalence rates, such as schizophrenia, receive much more attention. This discrepancy explains why many psychiatrists do not feel confident managing eating disorders,17 resulting in serious harm or the death of the patient, as was reported by the parliamentary ombudsman.1
Strengths and limitations of the study
To our knowledge, this is the first study to investigate eating disorder training during the whole medical education structure in the UK. The strengths of our study are that it has included all medical schools and all postgraduate specialty training programmes, which may have a role in managing this patient population. The response rate from medical schools was 93%. All relevant postgraduate curricula were reviewed, but we did not receive information about the exact number of questions in postgraduate examinations. However, as most curricula only included limited details on the topic, it is highly likely that examination is minimal.
We did not survey individual deaneries regarding delivery of teaching. This was beyond the scope of this study, but could be a subject of further research.
Conclusions and recommendations
Our findings mirror research in other countries, including the USA, Canada and Nordic Countries. We would like to repeat the call for improving medical training to meet the needs of this patient population.18–20 28
The Shape of Training review has set out the direction for the future of medical education in the UK: ‘Postgraduate training needs to adapt to prepare medical graduates to deliver safe and effective general care in broad specialties'. There will be an increased emphasis on developing general and transferable medical skills, and the need for more generalists, who can manage patients with multimorbidities rather than the expansion of subspecialisation.29
Although the document is mainly concerned about the needs of the ageing population, all common diseases associated with multimorbidity should receive sufficient attention during medical education. In this context, it is important that all doctors have sufficient knowledge of eating disorders, which affect 1%–4% of the population. With a small investment and better coordination between the different stages of specialty training, patient safety and outcomes could be much improved. Research estimates that the economic cost of eating disorders is approximately around £6.8 billion to £8 billion annually in the UK.30 This could be significantly reduced by early recognition and treatment, and doctors have a primary role in helping to achieve this.
Parity of esteem was enshrined in law in the UK by the Health and Social Care Act 2012. However, achieving parity of esteem is not possible without addressing the historical tradition of compartmentalising medical training into physical and psychiatric silos: psychiatrists need to be knowledgeable about nutrition and physical complications, while GPs and hospital specialists need to have a good understanding of various mental disorders and their complications.
Patient safety and outcomes could be improved by the following:
Medical schools: all medical schools should deliver training in eating disorders, including nutritional, psychiatric and ethical and legal aspects. The GMC is planning to introduce a new final Medical Licensing Assessment (MLA) in the near future. This should include questions on eating disorders, particularly about recognition and management of risk to life, which all doctors should be able to do. This would be in line with the GMC’s aim of the MLA ‘to create a single objective demonstration that those applying for registration… to practice medicine in the UK meet a common threshold for safe practice’ (http://www.gmc-uk.org/education/29034.asp).
Foundation training: opportunities for clinical experience should be widened, and assessment in WPBA should specify competencies relating to eating disorders; particularly the recognition and management of risk to life related to malnutrition, and the legal framework if the patient refuses treatment. This could be incorporated into the increasing number of psychiatric placements during foundation years.
Core and specialist training: the divide between mental and physical disorders during training should be reduced, so that all doctors can have a good understanding of both. This would support the recent ‘Ban the bash’ campaign by the Royal College of Psychiatrists, and improve parity of esteem. Without appropriate training, stigma against psychiatric patients, including eating disorders, is unlikely to be reduced. All doctors need to be aware of the risks associated with eating disorders and malnutrition and the available treatment options recommended by the National Institute for Health and Care Excellence (NICE). The assessment of specific competencies should be introduced for all relevant specialties.
Psychiatry training: all psychiatrists to have skills and competencies in eating disorders: at the very minimum, this should include risk assessment and management, with the threshold for compulsory treatment and NICE-approved treatments. This is necessary as the number consultant psychiatrists specialising in eating disorders is small and the out of hours duties are shared between all subspecialties. It would be helpful to include assessment of ED clinical competencies in ARCP and make sure that the MRCPsych examinations test related theoretical and clinical knowledge.
Non-training posts should include eating disorder training as part of continuing professional development (CPD) requirements for relevant specialties.
Eating disorder psychiatry credentialing would provide an additional training structure post-CCT level, and would standardise requirements for psychiatrists choosing this specialty.
This is the first study examining the whole pathway of medical education from undergraduate to postgraduate training for all relevant specialties in the UK.
Eating disorder teaching and assessment is <2 hours during the 10–16 years of undergraduate and postgraduate medical training in the UK.
There is an opportunity for significant improvements in patient safety and outcomes if this area was given more attention at all stages of medical education. This would only require a relatively small investment for large gains.
Current research questions
What is the best way of integrating clinical skills and knowledge of eating disorders at all stages of medical education?
How can medical education bodies coordinate their curricula?
How can assessment of relevant skills and knowledge be strengthened?
The authors would like to thank FOI officers and colleagues, who have helped with the data collection, Jonathan Kelly, Policy and Research Officer at B-EAT and Andrew Ayton for copy editing.
Contributors Both authors equally contributed to this paper. AA and AI designed the study following a series of near-miss incidents. Both authors contributed to the data collection, analysis and writing the paper. Both authors revised it critically for important intellectual content and approved the final version for publication. Both authors agree to be accountable for all aspects of the work.
Competing interests None declared.
Patient consent Not required.
Ethics approval The project was approved by Oxford Health Foundation Trust Audit and Quality Improvement Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The data file is available on request from AA.
Correction notice This article has been corrected since it was publsihed Online First. The title has changed to read: ’Does UK medical education provide doctors with sufficient skills and knowledge to manage patients with eating disorders safely?'