Eating Disorder education for pediatric residents
Shelly Ben Harush Negari
Description
Eating disorders (ED) are characterized by persistent disturbance of eating that impairs health
and psychosocial functioning. Anorexia Nervosa has the highest mortality rate of all psychiatric
illnesses. ~50% of mortality cases in anorexia are due to medical complications. Starvation
harms every organ system in the body and causes physical morbidity on top of the mental
illness (Rosen & American Academy of Pediatrics Committee on, 2010). The onset of eating
disorders (ED) is usually during puberty and often the primary care provider has the
opportunity for early diagnosis and treatment or referral to eating disorder experts for
treatment; however pediatricians and family physicians often lack training in ED diagnosis and
treatment. Early diagnosis of ED and intervention is crucial and related to improved outcomes
(Golden et al., 2015). The medical provider has a role in the primary assessment of ED, in the
assessment of the level of malnutrition and its complications, as well as the assessment of the
patient’s psychological state and dangerous eating behaviors. It is beneficial for pediatric
residents to learn how to diagnose and manage an ED patient. They will likely manage these
patients during their hospital career but more importantly as community pediatricians and in
many pediatric subspecialties. Currently there are no standardized guidelines in regards to
training pediatric residents on ED.
Curriculum Goal
I intend to go back to Israel and establish a new adolescent medicine program that will include
eating disorders clinic. In Israel, current training in ED management is minimal. Residents are
expected to know about ED diagnostic criteria for pediatric board (IMA, 2015) but primarily,
learning is done individually through textbooks. I developed a curriculum on eating disorders
for pediatric residents. The overall goal is for pediatric residents to gain the knowledge,
attitude, and skills required for diagnosing ED, identifying the medical complications and
managing the medical stabilization and treatment of the illness .
Target learners
My target learners are pediatric residents in Shaarei Tzedek hospital in Jerusalem. I originally
intended to establish my clinic in a different hospital in Israel and conducted an e-mail survey to
assess the need in such a curriculum. The response group included 2 faculty members and 2
community pediatricians who completed their pediatric residency, and 2 current pediatric
residents. 5 out of 6 responders reported treating minimal amount (1-5) of patients with ED in
the past year. They reported even lower rates of diagnosing ED themselves. (2 responders
never diagnosed and 3 diagnosed 1-5 cases). Most of the responders (4/6) reported low level of
confidence in diagnosing ED and its medical complications. All the responders reported having
no confidence in treating ED in an ambulatory clinic. Therefore I believe that there is a need in
such an education.
Schedule and plan
The overall teaching on eating disorder will include 3 methods:
Teaching method
Bed side teaching
Activity
Bed side teaching at
morning rounds
Didactic activities
Team based learning
session 1:
Introduction, data
gathering
Team based learning
session 2: group
presentations
Role play and small group
discussions
Shadowing in the ED
ambulatory clinics
Residents will shadow in
multidisciplinary ED clinic
Topic
Review of the primary
management of ED patients
admitted overnight. Monitor for
ED complications.
ED presentation and
complication
The multidisciplinary team work
and treatment strategies,
communication with the family
of ED patient
Multidisciplinary team work,
communication with the family
of ED patient
Time
Inpatient
rotation
Afternoon
conference
1 hour
Afternoon
conference
1 hour
Afternoon
conference
1.5 hour
Outpatient clinic
rotation
Cognitive objectives:
1. By the end of the curriculum, each resident will be able to identify various clinical
presentations of ED and be able to classify them according to the different diagnoses
2. By the end of the curriculum, each resident will be able to List 5 complications of
Anorexia Nervosa and 3 of Bulimia Nervosa
3. By the end of the curriculum, each resident will be able to describe the correct clinical
management of medically unstable ED patient
Behavioral objective:
Each resident will be able to discuss treatment options for ED patient in a role play activity
Attitude objective:
The residents will recognize the importance of a multidisciplinary approach to ED treatment
Outcomes
TBL activity:
1. The pediatric resident will work as a group to create consensus answer to the
knowledge pre- test
2. The residents in each group will create a presentation summarizing a specific topic
about eating disorder
3. Each pediatric resident will provide feedback to other group’s presentation.
Role play and small group discussion:
1. Each pediatric resident will simulate a discussion between a patient and a physician
or a patient family member and a physician in role activity.
2. By the end of the role play activity the resident will identify the challenges in
communication about eating disorder issues.
Strategy
In order to help the residents recognize the importance of a multidisciplinary team work and to
help them understand the role of each team member in the care of eating disorder patients I
created a maze (attached as artifact) that follows the phases of treatment. The learner needs to
help the animated patient cross the maze to recovery. In this journey to recovery the resident
meets the different care providers and their role in the care. Following the tip about cognitive
flexibility, the maze also serves as a way to understand this illness from the patient’s
perspective and to see that sometimes the medical system can appear complicated as a maze. I
hope that by solving the maze the learners will get the chance of experiencing the detailed
picture but also have a general vision of the big picture. The Maze will be given as an
introductory to the adolescent rotation before the residents shadow in clinic or work in the
inpatient unit. Currently I created a paper version but ultimately would like to create an
interactive Pac-man version.
Ethics
I will include specific guidelines regarding the use of source materials for the presentations.
Also prior to the inpatient rotation and the outpatient rotation there will be a discussion about
confidentiality. The work with eating disorder patients and their family often includes revealing
of intimate information about the families. As part of the training the residents will learn how
to be sensitive during these fragile conversations and how to make sure the patient’s
information is not shared with others.
Artifacts
1.
2.
3.
4.
Description of TBL learning activity+ assessments+ rubrics for grading TBL activity
Maze on eating disorders
Screen cast of graphic design for the neurobiologic etiologies of eating disorders
Survey sent to pediatric residents to assess the need in the curriculum
Golden, N. H., Katzman, D. K., Sawyer, S. M., Ornstein, R. M., Rome, E. S., Garber, A. K., . . . Kreipe, R. E.
(2015). Update on the Medical Management of Eating Disorders. Journal of adolescent health, 16.
IMA. (2015). ‫ תחומי‬-‫ סילבוס מורחב‬-‫[ ידע פרטניים רפואת ילדים‬pediatric medicine- extended sylabusspecific knowledge fields] Retrieved from
http://www.ima.org.il/Internes/ViewCategory.aspx?CategoryId=6908#.VNgSrGd0xjo
Rosen, D. S., & American Academy of Pediatrics Committee on, A. (2010). Identification and
management of eating disorders in children and adolescents. Pediatrics, 126(6), 1240-1253.
doi:10.1542/peds.2010-2821