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t age 78, Dr. Richard MacKenzie is having his Hollywood moment.

He’s the physician who helped inspire a controversial Netflix movie about anorexia, “To the Bone,” which begins streaming on Friday. The film was written and directed by one of his former patients, Marti Noxon. She has credited MacKenzie with helping her overcome her struggles with anorexia and bulimia.

But “To the Bone” is hardly a faithful portrait of his work. Over a long but under-the-radar career at Children’s Hospital Los Angeles, MacKenzie focused on keeping patients in their homes, rather than admitting them to an inpatient treatment center. He was known for working with his patients, with warmth and sensitivity, to help them identify the issues behind their eating disorders.

His character in “To The Bone,” by contrast, is brusque and edgy — and runs a group home to treat patients with anorexia.

MacKenzie never worked in such residential treatment centers and has watched their rise with skepticism. They promise a tranquil and nourishing atmosphere in which to recover, and they’re increasingly popular; there are now more than 75 such centers, nearly quadruple the number a decade ago, according to a count published last year. But their treatments are rarely fully covered by insurance and they often offer services, like equine therapy, that aren’t based in evidence.

And that’s not the only bit of artistic license Noxon has taken. The physician character, played by the actor Keanu Reeves, also has a penchant for profanity.

“He uses language in that film that I would never use,” MacKenzie told STAT.

The film, which was first released at Sundance Film Festival, has sparked a lively and at times contentious discussion on social media even before its debut on Netflix. An online petition to block the film’s release had nearly 700 signatures as of Monday afternoon.

One big concern is that it may glamorize eating disorders and trigger patients in recovery to return to harmful behaviors. Critics have also noted that the film’s star — the actress Lilly Collins — is a stereotypical version of a patient with anorexia: a young, white, pretty, rail-thin woman. Activists have been working to raise awareness that eating disorders afflict patients of all backgrounds, including boys and men and people who look to be a healthy weight, or even overweight.

To The Bone
Keanu Reeves (left) plays a character based on Dr. Richard MacKenzie in “To The Bone.” Netflix

Another flash point for critics: Collins deliberately lost weight for her role, in consultation with a nutritionist, even though she has a history of an eating disorder.

Still more criticism has centered on the film’s trailer, which flashes over Collins’s spine protruding out of her back and features a joke likening meticulously counting calories to Asperger’s syndrome.

That outcry was so great that Noxon had to put out a statement defending the film as “a conversation starter about an issue that is too often clouded by secrecy and misconceptions.”

For his part, MacKenzie doesn’t think the film glamorizes eating disorders. “I don’t think there are any triggers in there that young people of today are not already exposed to,” he said. But he concedes that the film “normalizes” the behavior of people with anorexia: Scenes of patients laughing and chatting like normal teenagers may be necessary to make an engaging movie, he said, but they’re a far cry from the often isolating reality of having an eating disorder.

MacKenzie wasn’t a formal consultant on the film, but he did make a few contributions. He watched an early cut of the movie and offered some advice to Noxon: Get rid of a happily-ever-after ending to a romance between two teenagers in treatment for their eating disorders, an outcome that would likely be unrealistic for patients with such severe illness. He was pleased to see that the happy ending had been replaced by one with more nuance in the final cut.

MacKenzie also helped Reeves prep for his role. They spoke on the phone for 30 minutes at the start of production; Reeves peppered him with questions about his style and his background. Not that much of that research appears to have made it into Reeves’s portrayal: Before a screening of the film late last month, MacKenzie ribbed the actor by joking that they didn’t have much in common beyond their shared Canadian heritage.

Shaping care for countless teenagers

MacKenzie trained in internal medicine at McGill University and cut his teeth treating street youth in Montreal. In 1969, he headed west to California for what was supposed to be a one-year fellowship in adolescent medicine at Children’s Hospital Los Angeles. He never left.

His focus on eating disorders was shaped by an early experience treating a teenage boy believed to have an eating disorder — a rare demographic for a condition almost always seen then, as it is now, as afflicting girls and women.

In retrospect, MacKenzie isn’t sure that that patient’s condition would be considered a bona fide eating disorder today. But the case was a springboard that helped MacKenzie develop a reputation as a physician willing to take on the most challenging eating disorder cases at a time when diagnoses were infrequent and resources were sparse.

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MacKenzie never published widely on eating disorders, nor is he considered a major contributor to the field. But he shaped care for countless teenagers in body image-conscious Southern California, where he spent 34 years as director of adolescent medicine at Children’s Hospital Los Angeles.

His style, he said, was to approach treating eating disorders less as a protocol-based “science of intervention” and more as “an art of interaction.”

He prescribed antidepressants sparingly. He recommended meditation.

Dr. Richard MacKenzie
A photograph of MacKenzie from the early 1980s is pinned to a collage of images he has up in his house in the Los Angeles area. Dania Maxwell for STAT

And in a strategy which was relatively rare in the 1970s and 1980s but widely practiced today, he encouraged patients to reflect on the root of their condition by writing in a journal. Among his patients, he said, Noxon in particular embraced that advice on her way to recovering from her eating disorders and becoming a prominent TV writer.

“The thing that my doctor did for me that so few people were doing was frame it not as a problem I had with food or my body, but a problem I had with my soul,” Noxon told the Washington Post. (She didn’t return STAT’s interview requests placed on Twitter and through a Netflix spokeswoman.)

A controversial approach

MacKenzie said that some of his ideas provoked controversy in the field. Among the most contentious, he said, was his advocacy to have a single physician take charge of a case and play down the role of therapists and nutritionists. “People would throw chairs at me for that,” he recalled.

Also controversial was his decision to have patients face away from the scale when he was weighing them, so they couldn’t see their weight. He also shunned discussion of calorie counts in talking about nutrition, trying instead to root the conversation in more tangible terms. And he believed most patients could be treated in their own homes — an approach that some physicians worry can lead to patients losing too much weight and waiting too long before seeking intensive inpatient physical and psychological treatment.

Today’s eating disorder specialists are divided on whether to let patients see their weight. They also disagree on the best therapeutic approaches, or combination of approaches, said Dr. Rollyn Ornstein, a pediatrician at Penn State Hershey Children’s Hospital who primarily treats patients with eating disorders.

Perhaps the biggest shift in the field in recent decades, Ornstein said, is the elevation of parents in providing care to their teenagers — a contrast to the 1980s, when the prevailing mentality was “drop your kid off, see you later, we’ll talk to you once a week and fill you in.” Indeed, a parent-guided therapeutic approach that focuses on symptoms rather than family dynamics is the only “well-established” treatment for teenagers with anorexia, according to a 2015 review of the evidence behind eating disorder treatments.

As for MacKenzie, he has retired from seeing patients, but he still helps train young doctors. Among those he’s mentored is Dr. Lindsey Brucker, an eating disorder specialist at the Los Angeles-area Torrance Memorial Medical Center who last year completed a fellowship program at Children’s Hospital Los Angeles.

MacKenzie, she said, is her model for building rapport with patients. He’s also the reason she encourages her own patients to write in journals.

“I essentially learned basically everything I know about eating disorders — and certainly the art of treating eating disorders — from Dr. MacKenzie,” she said.

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  • I totally agree with his not allowing his patients to see the scale. When I was at the height of my anorexia, I weighed myself 8 times a day and if I gained a pound, I would starve myself until I lost 5 pounds.

    The unfortunate reality to all of these films is that they don’t really reach the depth of this disease. I know it’s a hard thing to capture in a movie but maybe more inner dialog through the character writing in a private journal would help people understand better. It really is all about what’s going on in the anorexic’s mind.

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