Psy.D

So taboo it merits barely a whisper in the literature, the subject of eating disorders among American medical students, residents, and physicians often hides behind a cloak of anonymity on virtual bulletin boards. One such posting:

Does anybody have any experience with dealing with an eating disorder and being in med school? I’ve recently been told I’m no longer able to participate in clinical work (i’m in 3rd year) because my doctor contacted the school in regards to my health. I’m not underweight and my electrolyte balance is normal. I’m just looking for anybody who has been in a similar situation or anybody who might have any advice or support – it’s been a tough little while. ... I’ve made many positive changes, stopped abusing phentermine and ephedra, stopped overexercising, but apparently it hasn’t been enough.

Physicians seek treatment for eating disorders from individual physicians and eating disorders programs, but often only after taking desperate measures to control the disorder themselves, taking advantage of knowledge and medical insight beyond the reach of even the most well-read consumer seeking an out.

"Of course, there is a lot of individual-to-individual variation, but if I compile all of my experience, I would say physicians are more resistant than others to recognize and come to terms with the idea that they have a serious problem and they need help," said Dr. Ovidio Bermudez, chief medical officer of the Eating Recovery Center in Denver and past president of the National Eating Disorders Association.

A genetic predisposition to eating disorders likely occurs no more frequently in the families of medical professionals than in any other, but certainly the environment that nourishes young doctors contains abundant seeds for triggering the disorder, according to eating disorders specialists.

"I think it is more rampant than people know. These are high achievers, and the pressure is on," said Dr. Vicki Berkus, medical director of the eating disorders program at Sierra Tucson Treatment Center in Arizona.

Medical school and residency training are particularly challenging for those at risk, combining competition, stress, and wildly erratic schedules for eating, sleeping, and self care, agreed Dr. Jennifer L. Gaudiani, assistant medical director the ACUTE Center for Eating Disorders at Denver Health.

"Temperamental traits such as perfectionism, rigidity, and anxiety can be very useful in the pursuit of a medical career," Dr. Gaudiani said in a telephone interview. "A lot of us share them and have done very well by them."

But against the backdrop of a fat-phobic, diet-obsessed culture and those hard-driving personality traits, the uniquely stressful professional demands that are inherent in medical training and beyond may unmask disordered eating or sharply accelerate patterns left over from adolescence.

"Whoosh," said Dr. Gaudiani. "It’s a bonfire."

Secrecy complicates the issue and often adds fuel to the disorder.

"Doctors can be an unusually unsympathetic group when it comes to colleagues’ illnesses of any kind," she noted.

Underpaid, overworked residents are virtual poster children for compassion fatigue, notoriously tough on "colleagues not able to pull their weight," said Dr. Gaudiani.

So most residents with the disorder hide the problem as do many physicians in practice.

"Depending on the severity, it’s harder to hide anorexia," said Dr. Berkus, past president of the International Association of Eating Disorders Professionals.

Compulsive overeating and purging and/or laxative use can be concealed for some time, she added. Compulsive exercise can be seen as not only socially acceptable but also admirable, especially among professional men.

In lecturing to medical school classes about their risk for eating disorders, however, Dr. Berkus said, "It’s not unusual to see people tearing up, and two or three people will come up afterward to find out where they can get help.

"It takes so much energy to keep the secret."

Some medical professionals plaintively, but anonymously, appeal for advice on such websites as Student Doctor Network.

I have binge eating disorder and been in medical school for a year and a half. I’ve been in recovery for a while, but sometimes I have setbacks and become a whole different person. There’s a lot of unconciousness about eating disorders, I mean, as medical students, we all know what they are all about, but we don’t even take them as serious as we should. Eating disorders are illnesses just like diabetes and cancer and there’s no cure, just treatments to control them. I just want to know if there’s the experience of dealing with an eating disorder (the depression, lack of concentration, and neurosis that are involved) and the stress, lack of sleep, and amount of work that involves medical school. Although this is serious, I know several attendings and professors that don’t really care about it, so is it correct to mention it [in residency] interviews?

Responses to the posting filtered in on the bulletin board, ranging from supportive notes of encouragement to harsh responses from colleagues who questioned whether a person with an eating disorder can competently serve patients or keep up with the pace of training or medical practice.

Wrote one: Despite how good a narrative it may seem to you to be bouncing back and striving forward, medicine is an extremely high pressure lifestyle that can wreak havoc on anyone, and stress/sleep/competition are primary triggers for a range of mental illnesses. It does no one any good, not society, not to yourself, to have some med student break down, or a resident wash out, or yet another doctor commit suicide.

The fear of discovery or being rejected by and drummed out of the profession, casts a dark shadow over professionals struggling with eating disorders, emphasized Dr. Berkus.

"In a person with an eating disorder, the message that ‘you don’t belong,’ can be a universal message that they’ve carried for a long time," she said.

On the website, some medical students questioned the judgment of program coordinators who insisted the poster get help before continuing her studies.

Said one: Exactly what danger is this person in risk of? Passing out while rounding? Erosive esophagitis? Neither of these truly present a risk to the patient. "Danger to others" implies explicit threats, or impaired behavior, e.g., substance abuse. Certainly she is placing her own body at risk, but what about those who overeat and place themselves at risk for other complications?

Some professionals ultimately decide to step away to seek treatment, which can be lengthy and expensive. On a website in the United Kingdom, a student posted: I was supposed to start my residency (how do you call it? Internships?) next month, but i decided to stop my study for a while. I just physically/mentally cannot handle it right now. It is so sad ... Another disadvantage i developed because of my ED: I faint! Another taboo in the medical field! I used to love watching surgery, now I’m not so sure. I’m much too scared to pass out.

By the time medical students and physicians seek help, they often require inpatient hospitalization because of the extent of the medical and psychiatric complications of their disease, said Dr. Bermudez.

"I don’t think many physicians, young or old, graduated or not, are willing to recognize how serious the issue is.

"Denial is part and parcel of the eating disorder mentality but, in doctors, it runs a little deeper. Medical training reinforces that mind-set of, ‘I can handle it’ or ‘I have it under control to the ‘nth degree.’

"Generally speaking, we don’t make the best patients."

On the other hand, medical professionals, like other eating disorders patients, "absolutely can recover," when they fully commit to treatment, returning to successfully complete their training or reclaim a vibrant office or clinic practice.

"Eating disorders are treatable illnesses, much like depression," stressed Dr. Bermudez. "The propensity remains with an individual – [he or she maintains] the vulnerability factors, but those can go back to being under check."

Anecdotally, he’s seen it happen, as have the other experts interviewed for this story. But data chronicling the prevalence of eating disorders in the medical profession, their severity or their prognosis, are scarce.

Remarkably, the most recent study documenting the prevalence of eating disorders among U.S. medical students was published in December 1985 (J. Nerv. Ment. Dis. 1985;173:734-7). The article reported a 15% lifetime prevalence of an eating disorder among 121 female medical students aged 19-36 years. Specifically, 10 had a past history of bulimia, 5 had a current history of bulimia, and 4 had a history of anorexia nervosa.

However, the study preceded publication of the DSM-IV by many years, and subsequent studies have determined that anorexia nervosa, in particular, is diagnosed significantly more often under DSM-IV criteria.

Current dissertation research by a doctoral psychology student at Midwestern University in Downers Grove, Ill., has more recently found a prevalence of significant eating disorders and behaviors of nearly 13% among 700 male and female graduate health care professionals, including medical students.

That rate, according to Midwestern behavioral medicine professor Ann Sauer, Ph.D., "was very similar to that found in the general population ... [with] no significant difference in the rate of eating disorders attitudes and behaviors among the different disciplines."

"Working in a medical school/graduate school setting, I have also found that there is a real lack of information available on this topic," said Dr. Sauer in an interview.

Until more is published, the story of eating disorders among physicians continues to be shrouded in anonymity and secrecy, providing only occasional glimpses of the toll taken on the profession in general and the struggle faced by individuals with anorexia and/or bulimia.

Last summer, in response to a New York Times blog about bullying in medical school, a friend memorialized a 51-year-old, Columbia University–trained physician, Dr. Connie L. Rizzo, who reportedly died of complications from anorexia. The poster, a former student, said Dr. Rizzo "told me that her medical school experience was so horrific that she remained traumatized from the incidents which occurred [there]...

"The slight, beautiful, shy, Italian immigrant student from a family of artisans with an IQ of 180 turned out to be a dedicated healer but died from complications brought on by anorexia. A few weeks before she died she told me that she dreamed of a flower whose petals were being torn off by angry weeds even as it just wanted its own little reach of sun."

Efforts by this newspaper to find out more details about Dr. Rizzo or the friend who poignantly memorialized her, were unsuccessful.

ACUTE Eating Disorders Unit Expands to Accommodate Need

A unique, intensive medical stabilization unit for patients with severe eating disorders is expanding, based on high demand, according to Dr. Gaudiani, assistant medical director for the Acute Comprehensive Urgent Treatment of Eating Disorders (ACUTE) Center at Denver Health.

Beginning in the fall of 2008, a five-patient inpatient unit opened there to serve eating disorders patients who delayed getting treatment until their conditions had destabilized to the point that, "to their astonishment, they were too sick to be served," even at dedicated inpatient eating disorders units within psychiatric facilities, she said.

The Center accepts only patients whose weight has fallen below 70% of ideal body weight.

The first 200 or so patients served by the center ranged in age from 17 to 65 years (mean, 27 years), and averaged a body mass index of 12.5 upon admission. The average length of stay was 2 weeks.

In response to increased demand, the unit is now expanding to eight beds and may further increase its census, said Dr. Gaudiani in an interview.

A report on outcomes published this year in the International Journal of Eating Disorders found that in the unit, 44% of patients had hypoglycemia, 76%, abnormal liver function, and 83%, abnormal bone density, and 45% developed refeeding hypophosphatemia. While on the unit, 92% had hypothermia (Int. J. Eat. Disord. 2012;45:85-92).

In the community, patients with severe eating disorders often are admitted to intensive care units for brief stabilization, which is "at best, a Band-Aid solution, and at worse, dangerous," since complications of refeeding can occur following discharge, said Dr. Gaudiani.

Once patients are stabilized at the ACUTE unit, they are transferred to inpatient residential eating disorders programs, and often fare well, she added in an interview.

Dr. Bermudez said the need for the unit, which collaborates with his center for psychiatric care, demonstrates the need for better education and training in eating disorders among medical professionals.

"Early recognition and timely intervention is of the utmost importance," he said.

When patients or families present to primary care or specialists in cardiology, ob.gyn., gastroenterology, or other subspecialties, physicians need to be alert for subtle symptoms in patients who may try to hide symptoms of the disease.

"It’s a clear area where we’ve got to chisel away at the obvious," said Dr. Bermudez.

"Loved ones quite often express the concern that they consulted with a physician who falsely reassured them about the seriousness of a patient’s condition. In defense of physicians, this is not a population that wants to be discovered."

On the other hand, certain medical conditions such as electrolyte imbalances or cardiac abnormalities, particularly in adolescents or young adults, should "make the light go off, so they say, ‘Aha!’ " he said.

A number of resources exist to educate physicians about promptly diagnosing eating disorders, including a video CME course offered by the American Medical Association and a 18-page downloadable pamphlet for professionals designed by the Academy for Eating Disorders.

Beyond distance learning or didactic training, however, awareness comes through "rubbing elbows with these patients for awhile" so that the patterns and behaviors intrinsic to the disorder become obvious, said Dr. Bermudez.

If physicians, medical students, and residents begin to recognize eating disorders in patients, they may also begin to see its signs and symptoms among themselves and their peers, he added.

So taboo it merits barely a whisper in the literature, the subject of eating disorders among American medical students, residents, and physicians often hides behind a cloak of anonymity on virtual bulletin boards. One such posting:

Does anybody have any experience with dealing with an eating disorder and being in med school? I’ve recently been told I’m no longer able to participate in clinical work (i’m in 3rd year) because my doctor contacted the school in regards to my health. I’m not underweight and my electrolyte balance is normal. I’m just looking for anybody who has been in a similar situation or anybody who might have any advice or support – it’s been a tough little while. ... I’ve made many positive changes, stopped abusing phentermine and ephedra, stopped overexercising, but apparently it hasn’t been enough.

Physicians seek treatment for eating disorders from individual physicians and eating disorders programs, but often only after taking desperate measures to control the disorder themselves, taking advantage of knowledge and medical insight beyond the reach of even the most well-read consumer seeking an out.

"Of course, there is a lot of individual-to-individual variation, but if I compile all of my experience, I would say physicians are more resistant than others to recognize and come to terms with the idea that they have a serious problem and they need help," said Dr. Ovidio Bermudez, chief medical officer of the Eating Recovery Center in Denver and past president of the National Eating Disorders Association.

A genetic predisposition to eating disorders likely occurs no more frequently in the families of medical professionals than in any other, but certainly the environment that nourishes young doctors contains abundant seeds for triggering the disorder, according to eating disorders specialists.

"I think it is more rampant than people know. These are high achievers, and the pressure is on," said Dr. Vicki Berkus, medical director of the eating disorders program at Sierra Tucson Treatment Center in Arizona.

Medical school and residency training are particularly challenging for those at risk, combining competition, stress, and wildly erratic schedules for eating, sleeping, and self care, agreed Dr. Jennifer L. Gaudiani, assistant medical director the ACUTE Center for Eating Disorders at Denver Health.

"Temperamental traits such as perfectionism, rigidity, and anxiety can be very useful in the pursuit of a medical career," Dr. Gaudiani said in a telephone interview. "A lot of us share them and have done very well by them."

But against the backdrop of a fat-phobic, diet-obsessed culture and those hard-driving personality traits, the uniquely stressful professional demands that are inherent in medical training and beyond may unmask disordered eating or sharply accelerate patterns left over from adolescence.

"Whoosh," said Dr. Gaudiani. "It’s a bonfire."

Secrecy complicates the issue and often adds fuel to the disorder.

"Doctors can be an unusually unsympathetic group when it comes to colleagues’ illnesses of any kind," she noted.

Underpaid, overworked residents are virtual poster children for compassion fatigue, notoriously tough on "colleagues not able to pull their weight," said Dr. Gaudiani.

So most residents with the disorder hide the problem as do many physicians in practice.

"Depending on the severity, it’s harder to hide anorexia," said Dr. Berkus, past president of the International Association of Eating Disorders Professionals.

Compulsive overeating and purging and/or laxative use can be concealed for some time, she added. Compulsive exercise can be seen as not only socially acceptable but also admirable, especially among professional men.

In lecturing to medical school classes about their risk for eating disorders, however, Dr. Berkus said, "It’s not unusual to see people tearing up, and two or three people will come up afterward to find out where they can get help.

"It takes so much energy to keep the secret."

Some medical professionals plaintively, but anonymously, appeal for advice on such websites as Student Doctor Network.

I have binge eating disorder and been in medical school for a year and a half. I’ve been in recovery for a while, but sometimes I have setbacks and become a whole different person. There’s a lot of unconciousness about eating disorders, I mean, as medical students, we all know what they are all about, but we don’t even take them as serious as we should. Eating disorders are illnesses just like diabetes and cancer and there’s no cure, just treatments to control them. I just want to know if there’s the experience of dealing with an eating disorder (the depression, lack of concentration, and neurosis that are involved) and the stress, lack of sleep, and amount of work that involves medical school. Although this is serious, I know several attendings and professors that don’t really care about it, so is it correct to mention it [in residency] interviews?

Responses to the posting filtered in on the bulletin board, ranging from supportive notes of encouragement to harsh responses from colleagues who questioned whether a person with an eating disorder can competently serve patients or keep up with the pace of training or medical practice.

Wrote one: Despite how good a narrative it may seem to you to be bouncing back and striving forward, medicine is an extremely high pressure lifestyle that can wreak havoc on anyone, and stress/sleep/competition are primary triggers for a range of mental illnesses. It does no one any good, not society, not to yourself, to have some med student break down, or a resident wash out, or yet another doctor commit suicide.

The fear of discovery or being rejected by and drummed out of the profession, casts a dark shadow over professionals struggling with eating disorders, emphasized Dr. Berkus.

"In a person with an eating disorder, the message that ‘you don’t belong,’ can be a universal message that they’ve carried for a long time," she said.

On the website, some medical students questioned the judgment of program coordinators who insisted the poster get help before continuing her studies.

Said one: Exactly what danger is this person in risk of? Passing out while rounding? Erosive esophagitis? Neither of these truly present a risk to the patient. "Danger to others" implies explicit threats, or impaired behavior, e.g., substance abuse. Certainly she is placing her own body at risk, but what about those who overeat and place themselves at risk for other complications?

Some professionals ultimately decide to step away to seek treatment, which can be lengthy and expensive. On a website in the United Kingdom, a student posted: I was supposed to start my residency (how do you call it? Internships?) next month, but i decided to stop my study for a while. I just physically/mentally cannot handle it right now. It is so sad ... Another disadvantage i developed because of my ED: I faint! Another taboo in the medical field! I used to love watching surgery, now I’m not so sure. I’m much too scared to pass out.

By the time medical students and physicians seek help, they often require inpatient hospitalization because of the extent of the medical and psychiatric complications of their disease, said Dr. Bermudez.

"I don’t think many physicians, young or old, graduated or not, are willing to recognize how serious the issue is.

"Denial is part and parcel of the eating disorder mentality but, in doctors, it runs a little deeper. Medical training reinforces that mind-set of, ‘I can handle it’ or ‘I have it under control to the ‘nth degree.’

"Generally speaking, we don’t make the best patients."

On the other hand, medical professionals, like other eating disorders patients, "absolutely can recover," when they fully commit to treatment, returning to successfully complete their training or reclaim a vibrant office or clinic practice.

"Eating disorders are treatable illnesses, much like depression," stressed Dr. Bermudez. "The propensity remains with an individual – [he or she maintains] the vulnerability factors, but those can go back to being under check."

Anecdotally, he’s seen it happen, as have the other experts interviewed for this story. But data chronicling the prevalence of eating disorders in the medical profession, their severity or their prognosis, are scarce.

Remarkably, the most recent study documenting the prevalence of eating disorders among U.S. medical students was published in December 1985 (J. Nerv. Ment. Dis. 1985;173:734-7). The article reported a 15% lifetime prevalence of an eating disorder among 121 female medical students aged 19-36 years. Specifically, 10 had a past history of bulimia, 5 had a current history of bulimia, and 4 had a history of anorexia nervosa.

However, the study preceded publication of the DSM-IV by many years, and subsequent studies have determined that anorexia nervosa, in particular, is diagnosed significantly more often under DSM-IV criteria.

Current dissertation research by a doctoral psychology student at Midwestern University in Downers Grove, Ill., has more recently found a prevalence of significant eating disorders and behaviors of nearly 13% among 700 male and female graduate health care professionals, including medical students.

That rate, according to Midwestern behavioral medicine professor Ann Sauer, Ph.D., "was very similar to that found in the general population ... [with] no significant difference in the rate of eating disorders attitudes and behaviors among the different disciplines."

"Working in a medical school/graduate school setting, I have also found that there is a real lack of information available on this topic," said Dr. Sauer in an interview.

Until more is published, the story of eating disorders among physicians continues to be shrouded in anonymity and secrecy, providing only occasional glimpses of the toll taken on the profession in general and the struggle faced by individuals with anorexia and/or bulimia.

Last summer, in response to a New York Times blog about bullying in medical school, a friend memorialized a 51-year-old, Columbia University–trained physician, Dr. Connie L. Rizzo, who reportedly died of complications from anorexia. The poster, a former student, said Dr. Rizzo "told me that her medical school experience was so horrific that she remained traumatized from the incidents which occurred [there]...

"The slight, beautiful, shy, Italian immigrant student from a family of artisans with an IQ of 180 turned out to be a dedicated healer but died from complications brought on by anorexia. A few weeks before she died she told me that she dreamed of a flower whose petals were being torn off by angry weeds even as it just wanted its own little reach of sun."

Efforts by this newspaper to find out more details about Dr. Rizzo or the friend who poignantly memorialized her, were unsuccessful.

ACUTE Eating Disorders Unit Expands to Accommodate Need

A unique, intensive medical stabilization unit for patients with severe eating disorders is expanding, based on high demand, according to Dr. Gaudiani, assistant medical director for the Acute Comprehensive Urgent Treatment of Eating Disorders (ACUTE) Center at Denver Health.

Beginning in the fall of 2008, a five-patient inpatient unit opened there to serve eating disorders patients who delayed getting treatment until their conditions had destabilized to the point that, "to their astonishment, they were too sick to be served," even at dedicated inpatient eating disorders units within psychiatric facilities, she said.

The Center accepts only patients whose weight has fallen below 70% of ideal body weight.

The first 200 or so patients served by the center ranged in age from 17 to 65 years (mean, 27 years), and averaged a body mass index of 12.5 upon admission. The average length of stay was 2 weeks.

In response to increased demand, the unit is now expanding to eight beds and may further increase its census, said Dr. Gaudiani in an interview.

A report on outcomes published this year in the International Journal of Eating Disorders found that in the unit, 44% of patients had hypoglycemia, 76%, abnormal liver function, and 83%, abnormal bone density, and 45% developed refeeding hypophosphatemia. While on the unit, 92% had hypothermia (Int. J. Eat. Disord. 2012;45:85-92).

In the community, patients with severe eating disorders often are admitted to intensive care units for brief stabilization, which is "at best, a Band-Aid solution, and at worse, dangerous," since complications of refeeding can occur following discharge, said Dr. Gaudiani.

Once patients are stabilized at the ACUTE unit, they are transferred to inpatient residential eating disorders programs, and often fare well, she added in an interview.

Dr. Bermudez said the need for the unit, which collaborates with his center for psychiatric care, demonstrates the need for better education and training in eating disorders among medical professionals.

"Early recognition and timely intervention is of the utmost importance," he said.

When patients or families present to primary care or specialists in cardiology, ob.gyn., gastroenterology, or other subspecialties, physicians need to be alert for subtle symptoms in patients who may try to hide symptoms of the disease.

"It’s a clear area where we’ve got to chisel away at the obvious," said Dr. Bermudez.

"Loved ones quite often express the concern that they consulted with a physician who falsely reassured them about the seriousness of a patient’s condition. In defense of physicians, this is not a population that wants to be discovered."

On the other hand, certain medical conditions such as electrolyte imbalances or cardiac abnormalities, particularly in adolescents or young adults, should "make the light go off, so they say, ‘Aha!’ " he said.

A number of resources exist to educate physicians about promptly diagnosing eating disorders, including a video CME course offered by the American Medical Association and a 18-page downloadable pamphlet for professionals designed by the Academy for Eating Disorders.

Beyond distance learning or didactic training, however, awareness comes through "rubbing elbows with these patients for awhile" so that the patterns and behaviors intrinsic to the disorder become obvious, said Dr. Bermudez.

If physicians, medical students, and residents begin to recognize eating disorders in patients, they may also begin to see its signs and symptoms among themselves and their peers, he added.

So taboo it merits barely a whisper in the literature, the subject of eating disorders among American medical students, residents, and physicians often hides behind a cloak of anonymity on virtual bulletin boards. One such posting:

Does anybody have any experience with dealing with an eating disorder and being in med school? I’ve recently been told I’m no longer able to participate in clinical work (i’m in 3rd year) because my doctor contacted the school in regards to my health. I’m not underweight and my electrolyte balance is normal. I’m just looking for anybody who has been in a similar situation or anybody who might have any advice or support – it’s been a tough little while. ... I’ve made many positive changes, stopped abusing phentermine and ephedra, stopped overexercising, but apparently it hasn’t been enough.

Physicians seek treatment for eating disorders from individual physicians and eating disorders programs, but often only after taking desperate measures to control the disorder themselves, taking advantage of knowledge and medical insight beyond the reach of even the most well-read consumer seeking an out.

"Of course, there is a lot of individual-to-individual variation, but if I compile all of my experience, I would say physicians are more resistant than others to recognize and come to terms with the idea that they have a serious problem and they need help," said Dr. Ovidio Bermudez, chief medical officer of the Eating Recovery Center in Denver and past president of the National Eating Disorders Association.

A genetic predisposition to eating disorders likely occurs no more frequently in the families of medical professionals than in any other, but certainly the environment that nourishes young doctors contains abundant seeds for triggering the disorder, according to eating disorders specialists.

"I think it is more rampant than people know. These are high achievers, and the pressure is on," said Dr. Vicki Berkus, medical director of the eating disorders program at Sierra Tucson Treatment Center in Arizona.

Medical school and residency training are particularly challenging for those at risk, combining competition, stress, and wildly erratic schedules for eating, sleeping, and self care, agreed Dr. Jennifer L. Gaudiani, assistant medical director the ACUTE Center for Eating Disorders at Denver Health.

"Temperamental traits such as perfectionism, rigidity, and anxiety can be very useful in the pursuit of a medical career," Dr. Gaudiani said in a telephone interview. "A lot of us share them and have done very well by them."

But against the backdrop of a fat-phobic, diet-obsessed culture and those hard-driving personality traits, the uniquely stressful professional demands that are inherent in medical training and beyond may unmask disordered eating or sharply accelerate patterns left over from adolescence.

"Whoosh," said Dr. Gaudiani. "It’s a bonfire."

Secrecy complicates the issue and often adds fuel to the disorder.

"Doctors can be an unusually unsympathetic group when it comes to colleagues’ illnesses of any kind," she noted.

Underpaid, overworked residents are virtual poster children for compassion fatigue, notoriously tough on "colleagues not able to pull their weight," said Dr. Gaudiani.

So most residents with the disorder hide the problem as do many physicians in practice.

"Depending on the severity, it’s harder to hide anorexia," said Dr. Berkus, past president of the International Association of Eating Disorders Professionals.

Compulsive overeating and purging and/or laxative use can be concealed for some time, she added. Compulsive exercise can be seen as not only socially acceptable but also admirable, especially among professional men.

In lecturing to medical school classes about their risk for eating disorders, however, Dr. Berkus said, "It’s not unusual to see people tearing up, and two or three people will come up afterward to find out where they can get help.

"It takes so much energy to keep the secret."

Some medical professionals plaintively, but anonymously, appeal for advice on such websites as Student Doctor Network.

I have binge eating disorder and been in medical school for a year and a half. I’ve been in recovery for a while, but sometimes I have setbacks and become a whole different person. There’s a lot of unconciousness about eating disorders, I mean, as medical students, we all know what they are all about, but we don’t even take them as serious as we should. Eating disorders are illnesses just like diabetes and cancer and there’s no cure, just treatments to control them. I just want to know if there’s the experience of dealing with an eating disorder (the depression, lack of concentration, and neurosis that are involved) and the stress, lack of sleep, and amount of work that involves medical school. Although this is serious, I know several attendings and professors that don’t really care about it, so is it correct to mention it [in residency] interviews?

Responses to the posting filtered in on the bulletin board, ranging from supportive notes of encouragement to harsh responses from colleagues who questioned whether a person with an eating disorder can competently serve patients or keep up with the pace of training or medical practice.

Wrote one: Despite how good a narrative it may seem to you to be bouncing back and striving forward, medicine is an extremely high pressure lifestyle that can wreak havoc on anyone, and stress/sleep/competition are primary triggers for a range of mental illnesses. It does no one any good, not society, not to yourself, to have some med student break down, or a resident wash out, or yet another doctor commit suicide.

The fear of discovery or being rejected by and drummed out of the profession, casts a dark shadow over professionals struggling with eating disorders, emphasized Dr. Berkus.

"In a person with an eating disorder, the message that ‘you don’t belong,’ can be a universal message that they’ve carried for a long time," she said.

On the website, some medical students questioned the judgment of program coordinators who insisted the poster get help before continuing her studies.

Said one: Exactly what danger is this person in risk of? Passing out while rounding? Erosive esophagitis? Neither of these truly present a risk to the patient. "Danger to others" implies explicit threats, or impaired behavior, e.g., substance abuse. Certainly she is placing her own body at risk, but what about those who overeat and place themselves at risk for other complications?

Some professionals ultimately decide to step away to seek treatment, which can be lengthy and expensive. On a website in the United Kingdom, a student posted: I was supposed to start my residency (how do you call it? Internships?) next month, but i decided to stop my study for a while. I just physically/mentally cannot handle it right now. It is so sad ... Another disadvantage i developed because of my ED: I faint! Another taboo in the medical field! I used to love watching surgery, now I’m not so sure. I’m much too scared to pass out.

By the time medical students and physicians seek help, they often require inpatient hospitalization because of the extent of the medical and psychiatric complications of their disease, said Dr. Bermudez.

"I don’t think many physicians, young or old, graduated or not, are willing to recognize how serious the issue is.

"Denial is part and parcel of the eating disorder mentality but, in doctors, it runs a little deeper. Medical training reinforces that mind-set of, ‘I can handle it’ or ‘I have it under control to the ‘nth degree.’

"Generally speaking, we don’t make the best patients."

On the other hand, medical professionals, like other eating disorders patients, "absolutely can recover," when they fully commit to treatment, returning to successfully complete their training or reclaim a vibrant office or clinic practice.

"Eating disorders are treatable illnesses, much like depression," stressed Dr. Bermudez. "The propensity remains with an individual – [he or she maintains] the vulnerability factors, but those can go back to being under check."

Anecdotally, he’s seen it happen, as have the other experts interviewed for this story. But data chronicling the prevalence of eating disorders in the medical profession, their severity or their prognosis, are scarce.

Remarkably, the most recent study documenting the prevalence of eating disorders among U.S. medical students was published in December 1985 (J. Nerv. Ment. Dis. 1985;173:734-7). The article reported a 15% lifetime prevalence of an eating disorder among 121 female medical students aged 19-36 years. Specifically, 10 had a past history of bulimia, 5 had a current history of bulimia, and 4 had a history of anorexia nervosa.

However, the study preceded publication of the DSM-IV by many years, and subsequent studies have determined that anorexia nervosa, in particular, is diagnosed significantly more often under DSM-IV criteria.

Current dissertation research by a doctoral psychology student at Midwestern University in Downers Grove, Ill., has more recently found a prevalence of significant eating disorders and behaviors of nearly 13% among 700 male and female graduate health care professionals, including medical students.

That rate, according to Midwestern behavioral medicine professor Ann Sauer, Ph.D., "was very similar to that found in the general population ... [with] no significant difference in the rate of eating disorders attitudes and behaviors among the different disciplines."

"Working in a medical school/graduate school setting, I have also found that there is a real lack of information available on this topic," said Dr. Sauer in an interview.

Until more is published, the story of eating disorders among physicians continues to be shrouded in anonymity and secrecy, providing only occasional glimpses of the toll taken on the profession in general and the struggle faced by individuals with anorexia and/or bulimia.

Last summer, in response to a New York Times blog about bullying in medical school, a friend memorialized a 51-year-old, Columbia University–trained physician, Dr. Connie L. Rizzo, who reportedly died of complications from anorexia. The poster, a former student, said Dr. Rizzo "told me that her medical school experience was so horrific that she remained traumatized from the incidents which occurred [there]...

"The slight, beautiful, shy, Italian immigrant student from a family of artisans with an IQ of 180 turned out to be a dedicated healer but died from complications brought on by anorexia. A few weeks before she died she told me that she dreamed of a flower whose petals were being torn off by angry weeds even as it just wanted its own little reach of sun."

Efforts by this newspaper to find out more details about Dr. Rizzo or the friend who poignantly memorialized her, were unsuccessful.

ACUTE Eating Disorders Unit Expands to Accommodate Need

A unique, intensive medical stabilization unit for patients with severe eating disorders is expanding, based on high demand, according to Dr. Gaudiani, assistant medical director for the Acute Comprehensive Urgent Treatment of Eating Disorders (ACUTE) Center at Denver Health.

Beginning in the fall of 2008, a five-patient inpatient unit opened there to serve eating disorders patients who delayed getting treatment until their conditions had destabilized to the point that, "to their astonishment, they were too sick to be served," even at dedicated inpatient eating disorders units within psychiatric facilities, she said.

The Center accepts only patients whose weight has fallen below 70% of ideal body weight.

The first 200 or so patients served by the center ranged in age from 17 to 65 years (mean, 27 years), and averaged a body mass index of 12.5 upon admission. The average length of stay was 2 weeks.

In response to increased demand, the unit is now expanding to eight beds and may further increase its census, said Dr. Gaudiani in an interview.

A report on outcomes published this year in the International Journal of Eating Disorders found that in the unit, 44% of patients had hypoglycemia, 76%, abnormal liver function, and 83%, abnormal bone density, and 45% developed refeeding hypophosphatemia. While on the unit, 92% had hypothermia (Int. J. Eat. Disord. 2012;45:85-92).

In the community, patients with severe eating disorders often are admitted to intensive care units for brief stabilization, which is "at best, a Band-Aid solution, and at worse, dangerous," since complications of refeeding can occur following discharge, said Dr. Gaudiani.

Once patients are stabilized at the ACUTE unit, they are transferred to inpatient residential eating disorders programs, and often fare well, she added in an interview.

Dr. Bermudez said the need for the unit, which collaborates with his center for psychiatric care, demonstrates the need for better education and training in eating disorders among medical professionals.

"Early recognition and timely intervention is of the utmost importance," he said.

When patients or families present to primary care or specialists in cardiology, ob.gyn., gastroenterology, or other subspecialties, physicians need to be alert for subtle symptoms in patients who may try to hide symptoms of the disease.

"It’s a clear area where we’ve got to chisel away at the obvious," said Dr. Bermudez.

"Loved ones quite often express the concern that they consulted with a physician who falsely reassured them about the seriousness of a patient’s condition. In defense of physicians, this is not a population that wants to be discovered."

On the other hand, certain medical conditions such as electrolyte imbalances or cardiac abnormalities, particularly in adolescents or young adults, should "make the light go off, so they say, ‘Aha!’ " he said.

A number of resources exist to educate physicians about promptly diagnosing eating disorders, including a video CME course offered by the American Medical Association and a 18-page downloadable pamphlet for professionals designed by the Academy for Eating Disorders.

Beyond distance learning or didactic training, however, awareness comes through "rubbing elbows with these patients for awhile" so that the patterns and behaviors intrinsic to the disorder become obvious, said Dr. Bermudez.

If physicians, medical students, and residents begin to recognize eating disorders in patients, they may also begin to see its signs and symptoms among themselves and their peers, he added.