The illnesses are relatively straightforward to diagnose, especially anorexia nervosa. There aren't that many reasons for an 18-year-old to be at a body mass index of 14. That one's pretty obvious. Bulimia is more difficult because it's an invisible condition.
Part of the problem is the total lack of exposure to these conditions in medical school curricula and residency training programs. In Toronto we have the largest residency training program, I think, in North America. We have 128 residents in the program. We have the largest program for eating disorders in the country. The total exposure to eating disorders that psychiatric residents—those are people who have graduated from medical school and are going to be psychiatrists—get in five years of training is two one-and-a-half hour lectures, and that's it. The situation for family practice residencies is even worse.
There's virtually no attention paid to this in medical school, so physicians graduate from medical school with no information available to them, no training, and no ability to do anything useful with these patients once they're identified. There's some room here for recommendations about curriculum in medical school, family practice residency programs, and frankly, psychiatry residency programs as well, because those institutions do an atrociously bad job of preparing their trainees to deal with this. Bulimia nervosa, in the core business group which is women ages 15 to 40, is nearly 3% of women ages 15 to 40. The percentage of bulimia in unhappy young women is very, very high.
I have a colleague who's an outpatient psychiatrist. Many, many years ago when we graduated, he went into private practice. As a favour to me, he added a couple of questions to his psychiatric review systems: have you ever been underweight; have you ever had binge eating; and, have you ever had vomiting? In his first 100 consultations, three people were referred for a clear eating disorder. He discovered 30 additional cases, mostly bulimia.
These are extremely common illnesses in family doctors' offices and in psychiatrists' offices, because these people are unhappy, so they're seeing their doctor or they're seeing a psychiatrist, and there is almost no training in these illnesses in medical school or residency.