Psychiatry trainee experience of working in a child and adolescent eating disorder program

Abstract

Objectives

Eating disorders are serious psychiatric conditions that affect people of all ages. Many psychiatry trainees' first and only experience with eating disorders during training is their Child and Adolescent Psychiatry (CAP) rotation. This study aimed to explore the learning experience of psychiatry trainees working within an Eating Disorder Program (EDP) during their CAP rotation.

Methods

Fifteen trainees who participated in the EDP were recruited to complete an online survey and focus groups; a thematic analysis design was used to identify themes emerging from their responses.

Results

Themes emerged from the trainee learning experience of working in the EDP around what they found they learnt, what aided that process, what was difficult, and recommendations for future improvement.

Conclusions

This study provided insight into the trainee experience in an EDP as one example of how trainees can learn about eating disorders and one way that could inform future workforce and training initiatives.

Eating disorders are complex and potentially life-threatening conditions requiring specialised psychiatric treatment that can occur at any age with a peak incidence in adolescence.^1,2 A large 10-year longitudinal study reported that children and adolescents had a 6.7% lifetime prevalence of developing an eating disorder. ² Despite the prevalence and risk of mortality associated with eating disorders, there are no mandatory eating disorder Entrustable Professional Activities (EPAs) that psychiatry trainees are required to undertake as part of the RANZCP Fellowship Program. ³ Eating disorder EPAs are available to be completed as part of elective rotations in a specialist eating disorder service, or in addition to mandatory EPAs during another rotation. This touches on the greater ongoing debate around a specialist versus generalist approach to psychiatry training in Australia and New Zealand, which is outside of the scope of this paper. ⁴ Regardless, at present it is not possible for all psychiatry trainees to work within a specialist eating disorder service. Therefore, exposure to clients with an eating disorder commonly takes place during the second and third years of training in the Child and Adolescent Psychiatry (CAP) rotations given the peak age of incidence of these disorders. ²

There is limited research into the trainee experience of working with young people with eating disorders and their families. There is also little evidence for how such experiences impact trainees’ perceived learning and comfort in working with clients experiencing an eating disorder following such a rotation and transitioning to fellowship.

Qualitative study designs can be used to explore these questions and have previously been used in examining the trainee experience conducting family therapy within a CAP setting and regarding the trainee experience of supervision.^5,6 Therefore, a qualitative design was chosen to examine the psychiatry trainee learning experience working within an Eating Disorder Program (EDP) during their CAP rotation. Trainees participated in the EDP within a tertiary community-based child and youth mental health service (CYMHS). In this program, Stage 2 and 3 trainees take on at least one client with an eating disorder. They are supported by the lead psychiatrist and the two senior EDP coordinators who oversee all clients with an eating disorder attending the service. The coordinators also manage the EDP team, who are available to support all clinicians and trainees within the service. The EDP-specific team consists of a dietician, family peer specialist, youth peer worker, and a rotating roster of the CYMHS nursing staff who are available to conduct physical health monitoring. Once a client is accepted into the EDP they are offered a first family meeting, where the EDP multi-disciplinary team (MDT) attends. Following this, the trainee will continue to see the client and their family with support available from the EDP coordinators and team. On a case-by-case basis, a trainee may also have the opportunity to work alongside an allocated co-clinician from CYMHS.

This paper aims to contribute a greater understanding of the learning experience of the trainees within an EDP and how this process could be improved to support their learning.

Methods

A qualitative study design using thematic analysis was used for this study.^7,8 This was further informed by basic quantitative data regarding the trainees experience within the EDP. ⁹ A total of 15 trainees were identified as having worked in the EDP in the preceding 12 months and were invited to participate in the study via email. All 15 trainees agreed to participate, provided informed consent, and completed the initial online survey based on the survey used by Cheah, Hopkins, and Whitehead. ⁵ The survey consisted of two Likert rating scale questions, seven yes/no questions regarding their rotation, and seven open-ended questions relating to their experience. Nine trainees also opted-in to participate in one of three focus groups. The focus groups were conducted by the corresponding author in a semi-structured interview format that allowed the participants to expand further on the themes identified within the online survey. The interview questions orientated the trainees to reflect on broad areas of their experience. These included the impact of their experience on their learning, what the program provided to support their learning, difficulties in the process, and what improvements could be suggested. The focus groups were audio-recorded and transcribed verbatim for thematic analysis.

Responses were coded and thematically analysed to uncover the potential benefits and issues of the trainee learning experience working in the EDP. Major themes were identified and elaborated on using an established thematic analysis six-step coding approach. ⁷

Availability of data and materials

Survey questions, detailed methodology, and data are available from the corresponding author on request.

Results

In response to the survey, 14 of the 15 trainees indicated ‘Yes’ they would recommend participating in the EDP to another trainee during their CAP rotation. The responses to the Likert-Scale survey questions are shown in Table 1.

Table 1.

Response to Survey Questions (n = 15)

Question 1.
Overall, how would you rate your experience working in the EDP?	Excellent	Good	Average	Fair	Poor
Number of trainees	5	6	4	0	0
Question 2.
How do you think the EDP contributed to the overall experience during your CAP rotation?	Very positive	Minimally positive	No contribution	Minimally negative	Very negative
Number of trainees	4	10	0	1	0

Thematic analysis

Themes emerging from the data were categorised into four main themes as initially guided by the research questions and elaborated on and explored through the coding process. Throughout this process, emerging patterns were analysed and grouped into subcategories. These are listed in Table 2 with representative statements from the trainee responses.

Table 2.

Description of Emerging Themes

Theme	Description
Trainee learning	The learning gained working in the EDP
Subcategories	Description	Significant Statement Example
Working with families	Feeling more comfortable working with families and the principles of family therapy as a therapeutic modality	‘...working as a clinician with eating disorders is a fantastic opportunity because they are so difficult, so entrenched in dynamics in a family and you can understand it at a textbook level, but then just describing at a textbook level is getting down into the nitty-gritty, ...observing the family and being a moving piece in the family and getting them to interact in a certain way or making observations in a certain way’.
Physical health monitoring and indications for escalating care	Understanding physical health monitoring requirements and indications for more assertive treatment of eating disorders	‘...I learned through the eating disorder program basic things like when to be worried physiologically about patients, admission criteria’.
Recovery-orientated practice	Using a recovery-orientated framework to be client and carer/family focussed, non-judgemental, and more comfortable with the dignity of risk	‘…the way it’s done at the outset very patient-centred, family-focused and letting the family and the young person have as much autonomy as possible in the situation’.
Treatment of eating disorders	Feeling more confident using specific treatment modalities that included Family-Based Therapy (FBT) and modified FBT approaches	‘I think the EDP is an invaluable experience which has taught me a lot about treating and managing eating disorders with the principles of FBT’.
Psychodynamic processes	Understanding the role of psychodynamic processes in working with young people with an eating disorder and their families	‘It assisted with understanding a family system from a psychodynamic viewpoint and how the family is balanced in order for a child to present with an eating disorder. By being forced to enter the family system as a clinician / case manager, you understand the relationships ...then can appreciate what needs to be done in order to shift the family to a place where the child's symptoms decrease’.
Utilising supervision	Feeling able to use supervision effectively to assist with the learning process	‘...things were getting risky and things weren't budging. I was having discussions with the eating disorder lead and my supervisor. Basically, the aha moment was like, look, we're all on the same page. We're all understanding things exactly the same way. I'm not missing anything. It's just a really difficult situation and that gave me the liberty to push in the ways that naturally came to me…...’
Benefits of the EDP	The aspects of the EDP that supported the trainees in their learning
Subcategories	Description	Significant Statement Examples
Flexibility	Utilising a flexible and collaborative approach to treatment planning assisted trainee learning	‘I probably initially was also very much going by an FBT approach. But over time, having spoken to different clinicians, a lot of people have said, well, sometimes you just have to be flexible and take a different approach. And I've seen that that works as well’.
Co-clinicians	Co-clinicians with experience in the treatment of eating disorders supported the learning process	‘It was usually with someone more senior in terms of an experienced psychologist or one of the senior clinicians, which was really helpful. And then you could at least see what the structure was like and think, okay, maybe I can do this’.
Supervision	Access to senior clinicians and lead EDP psychiatrist for supervision-supported trainee learning	‘At times I've had to seek the support, (and) when I have, it’s been met with seemingly bottomless empathy and support from the leaders, particularly the leadership team’.
Working in a multidisciplinary team	Collaborating within the MDT increased understanding and comfort in treating eating disorders	‘I did have the opportunity to have an MDT about one of my young people, a case I had a lot of anxiety about. Hearing from my more experienced colleagues and receiving positive feedback about approach did help, as I had been feeling like I was completely off track!’
Challenges in the EDP	The aspects of the EDP that were challenging for trainees
Subcategories	Description	Significant Statement Examples
Stress on the trainee	Stress from perceived and real expectations of the mental health service, families, and the trainees themselves when working with EDP clients increased trainee stress and discomfort that impacted on the learning experience	‘The stuff was very difficult and getting your head around managing risky and stressful situations and feeling things like you don't know what you're doing at all and whether that's contributing to a lot of negative outcomes that are playing out in the short term…...’
Difference from prior work	The difference between previous psychiatry training experience and having their first exposure to working with children, adolescents, and their families while also learning about the treatment of eating disorders was challenging for trainees	‘...I felt as though my previous training and experience was insufficient in providing me with the skills required when working with this patient group’.
Dual role of the trainee	Trainees balancing being a doctor on their team, while also being a primary case-manager working directly with the young person with an eating disorder created tension for trainees	‘I feel like there's an expectation within our program that communication goes by certain channels and that I think as doctors as well, sometimes additional information would be really helpful for us to know from the paediatric team, for example...I've got a very complex patient who has had a lot of medical investigations, and trying to stay on top of that has been really difficult’.
Liaison	Challenges arose in the liaison within the service around organising physical health monitoring and also with external mental health services and hospital inpatient units when clients were admitted	‘...having the inpatient service provided by a different service, we're not always on the same page, and it's not a smooth transition makes the whole treatment journey very difficult’.
Recommendations to Improve Trainee Learning	The experiences that trainees felt would improve their experience and learning
Subcategories	Description	Significant Statement Examples
Formal learning	Trainees recommended formal education course around eating disorders prior to starting work in the EDP	‘One thing that I found extremely helpful and I would recommend it to people who were coming to the team was I did online learning’.
Improved communication	Trainees indicated that improved communication and liaison both within the service and with inpatient units would improve their experience	‘Reducing the barriers around communication or having some kind of streamlined understanding between services around admissions and access of information’.
Clear expectations	Trainees indicated that consistently having a senior co-clinician allocated for their initial eating disorder client would benefit their learning	‘Support registrars with senior co-clinicians who have specialist eating disorder experience for the first few patients to understand how to run family meetings - it feels like you are driving in the dark at the start’.
Support/supervision	Trainees recommended that early, available, and accessible supervision would improve the learning experience	‘I found it very overwhelming as I had a couple of very tricky clients and it was difficult to figure out the best approach. In hindsight I probably should have reached out for help earlier/been more comfortable to say I wasn’t comfortable!’

Discussion

The qualitative findings of this study shed light on the learning experience of psychiatry trainees working with the EDP, with themes emerging around what trainees felt they learnt, what aided that process, what hindered their learning, and what they recommended for future trainees. The emerging subcategories within these themes were of interest as they identified areas where trainees felt they learnt the most. These themes indicated trainees had not only learnt the skills specific to treatments of eating disorders but also broader concepts within psychiatry. Themes of learning to work with families, recovery-orientated practice, and working with a psychodynamic focus were areas of learning that emerged from the trainee responses. These findings imply that the EDP was felt to be a way to learn a range of skills required to work with clients with an eating disorder, as well as learn more broadly applicable skills in psychiatry.

Trainees identified specific aspects of the EDP that aided this learning, with themes emerging around the role of supervision, observation of senior clinicians, working with co-clinicians, and working within the MDT. Trainees found benefit from not only working with a lead EDP psychiatrist but also through interdisciplinary supervision with the two EDP coordinators. This extended to trainees describing benefits from working directly alongside their co-clinicians from CYMHS. These concepts could be considered in future training. Utilising interdisciplinary supervision, co-clinicians, and an MDT while within a CAP rotation was felt by trainees to aid the learning experience and this could inform ways of expanding access to training opportunities in the future.

Conversely, there were aspects of working in the EDP that trainees felt detracted from the overall learning experience. One trainee felt that the EDP negatively impacted on their experience during their CAP rotation, as indicated by the quantitative data. This was supported by themes that emerged in the qualitative data around difficulties with the stress felt working with eating disorder clients, the differences from their previous experience in psychiatry, and difficulties in communication and liaison. Themes for improvement to the learning experience evolved from trainees’ proposed solutions to these difficulties. Trainees felt that adding formal training and orientation prior to the EDP would address some anxiety around starting to work with eating disorder clients and provide a theoretical basis for the work. Better utilising the available supervision, having an allocated senior co-clinician, and outlining clear expectations of the trainee role at the outset were also themes that emerged for improvement in response to feeling stressed or uncertain in their role.

Strengths and limitations

A strength of this study was that it was able to use a combination of open-ended survey question design and focus groups to identify themes around trainee learning where future support and training could be directed to better equip trainees with knowledge of eating disorders in the future.

However, there were also several limitations that could limit its generalisability beyond the specific EDP described. The authors and the trainees recruited for the study had personal experience working within this EDP in different capacities. The personal experience of the authors was reflected on during the coding process, and their positions within the service and own experience working with the EDP were used in analysing the themes as they emerged. This knowledge was not only used to limit ‘cherry-picking’ of only positive themes but is also acknowledged as a source of potential bias in thematic analysis.

Another limitation is the potential lack of generalisability to services with a different model of care for the treatment of eating disorders. While the themes and principles may be applicable to other service models, this was not specifically investigated in the current study.

Conclusion

Eating disorders are a complex group of mental health conditions increasing in prevalence in Australia that will require a psychiatric workforce with the skills and confidence to work in this area. The findings of this study demonstrate that working within the EDP as part of their CAP rotation was perceived by trainees as a way to learn skills needed in the treatment of eating disorders. Trainees found this work to be stressful, complex, and different from other experiences in psychiatric training. Providing further opportunities for trainees to work with clients with eating disorders during CAP rotations could help reduce trainee apprehension working in this area and assist with future workforce and training development.