I am a first-year medical student at the University of Kansas. My status, however, is almost up for expiration. In a mere 8 weeks I will have completed my first-year of classes. From the outside looking in, it would seem as if I am on the downward slope. I have taken 12 of my 16 didactic exams and have done well thus far.
Nevertheless, it is the last four exams that worry me the most. The block that we are in is titled, “GI and Renal,” a module that I knew I would find particularly difficult. The difficulty, unfortunately, does not stem from the content, but from my past struggles with anorexia nervosa. The gastrointestinal (GI) system on a very basic level simply follows the food that you put in your mouth and its route throughout the body. For most students, it’s a simply bit odd. For a recovering anorexic, it is extremely triggering.
The first hospital unit that I worked in as an undergraduate student was in the gastrointestinal surgical unit. And no, I did not volunteer for this position because of the magical smell of C. difficile and the frequent \ bloody diarrhea. At my sickest, I remember approaching the attending physician at one point—standing at a mere 5’5” and 115 lbs.—asking if he would ever consider me a candidate for a Roux-En-Y surgery. The surgery requires the surgeon creates an anastomose (or think of a “connection” that is not normally present) between the small intestine and the upper portion of the stomach. The Roux-En-Y not only “shrinks” the stomach, the procedure also prevents an adequate absorption of nutrients. It is reserved for only the most clinically obese patients who have failed both lifestyle interventions and pharmacologic treatment. On paper, the surgery requires a patient to have a BMI of > 40 for > 35 with at least 1 significant risk factor. Needless to say, I did not qualify.
But that did not stop me. I spent hours in that clinic: paging nurses, transferring patients, and rounding with the GI fellows. It was during this time that I fed my anorexia whilst concurrently starving myself. I studied the many enzymes required for proper digestion, the timeline of a meal, the many muscles and sphincters through which my breakfast—2 eggs and slice of 40 calorie toast—passed through each morning.
When I was finally diagnosed with anorexia, I was forced to eat. This, of course, did not address the actual problem and shortly after eating I would simply go home and throw up. I begin showing symptoms of bulimia nervosa. As a result, my dietician began to worry about an esophageal tear, a life-threatening medical emergency. In a desperate attempt to rid me of my habit, I remember her telling me that “purging does not negate the caloric intake” and that “the body, on average, retains more than 50% of the calories during a binge.”
I also remember looking at her dead in the eye and replying:
“Oh, I know. Normal binges tend to consist of carbohydrate heavy foods. Thus, amylase—the enzyme secreted within the oral cavity—begins breaking down the food as soon as it enters the mouth. That’s why I only binge on peanut butter and nuts—both of which are high in fats—fats, of course, cannot be sufficiently digested until the duodenum of the small intestine when the pancreatic enzymes hydrolyze the ester bonds within the lipids allowing for emulsification and proper digestion.”
I was promptly referred to see someone else.
It was truly ironic, objectively I knew what I was doing was wrong. I knew it all the way down to the molecular structure of glucose, yet I sided with my disease for so long.
In the first week of “GI and Renal,” we were given 4-hours of intensive gastrointestinal physiology. I later went into JayDoc—a safety net healthcare center that I, and many of my classmates, volunteer at—that night making comments about how simple and straightforward the lectures were. To my surprise, this feeling was not mutual amongst my peers. At first, I was simply baffled. It took me a second to remember that my classmates may not have spent each night of their sophomore year of college reading GI physiology. They most likely did not refuse to take their anti-anxiety medications that they had been on since they were 10-years old because they had just found out that an adverse side-effect of SSRIs is weight gain. So when I suggested in class that we switch our obese patient to bupropion instead of an SSRI to prevent weight gain, it was not because I spent extra time studying pharmacology for the lecture, but because I did that myself 2 years ago.
I was familiar with this material. I knew it all and I knew it well. Selecting a “Diet of 1200-1500 calories” as the correct answer on a practice exam was extremely triggering. Being asked to calculate BMI after BMI was worse. I began to relapse.
I began heavily restricted throughout the week while maintaining my normal workload. It was not until Saturday that my body had finally had enough. I went on a binge followed by a purge. This happened three times.
Eating disorders are not beautiful, and I have no idea why this concept of beauty is associated with such a terrible disease. I found myself kneeling in front of the toilet staring at remnants of a Cliff bar, some chocolate almonds, and a protein shake. I began to feel lightheaded and my vision began to blur. I began to panic. One well known side effect of bupropion is a seizure. This risk is significantly increased in patients suffering from bulimia nervosa due to the electrolyte imbalance caused by excessive purging.
It was time to stop. I washed my hands, gargled a cup of water, and pulled the Pedialyte from my closet that I kept just in case for emergencies like this. And then I did exactly what my eating disorder was screaming at me not to do. I asked for help.
I did not wait until my concerned teammates told my coach that they kept “hearing noises from the bathroom.” I did not wait for my physician to finally diagnose me with anorexia nervosa despite having “too high of a BMI.” I did not wait because I could not wait. I pressed “send” on a rather lengthy message and hoped for the best. It was 1AM.
To my surprise, I had an immediate reply and I truly cannot thank this person enough. It is times like these that I cannot reiterate how important it is to have a support group and how thankful I am to have mine. So why am I writing this obscenely long post you may ask? It certainly seems to apply to a very specific subpopulation, but this is not true.
I am open with my mental health because mental health within medicine continues to be so heavily stigmatized. I am open with my mental health because I have seen what happens when I am silent. I want to know what happens when I open my mouth.
I have had the honor of speaking with a variety of individuals who have fully recovered from their eating disorders and their stories inspire me. But I also think these stories are overrepresented within the community. I think it is also important to share my story, my incomplete story. I want people to know that you can still struggle with your mental health and that does not make it any less of a success story. I want people to know.
Update: Finished exam #1 in “GI and Renal,” 3 more to go!