Surgeons' knowledge and attitude regarding concepts of nutritional therapy

Abstracts

OBJETIVO: comparar o conhecimento e percepção em terapia nutricional (TN) de residentes de cirurgia e cirurgiões. MÉTODOS: foram aplicados dois questionários padronizados sobre conhecimentos, atitudes e condutas em TN de 50 médicos (35 residentes e 15 cirurgiões) de 12 áreas cirúrgicas distintas. Utilizando-se o teste exato de Fisher, com significância de 5% com p<0,05, foi comparada a proporção de acertos, de acordo com a percepção a respeito do assunto de cada grupo. RESULTADOS: mais de 80% não se sentiram seguros frente à TN e 46% negaram conhecimento de equipe multiprofissional de TN (EMTN). Houve maior percentual de acertos, dentre os residentes, nos itens: trauma operatório e sua influência nutricional no paciente (p=0,047); IMC normal (p=0,036); e TN no pré-operatório (p=0,007) e indicação da TN pré-cirúrgico no grupo que diz que interagem com EMTN (p=0,02). Dentre os cirurgiões: complicações da TN e TN em pacientes previamente desnutridos (p=0,044); e Métodos de avaliação nutricional no pré-operatório no grupo que diz que interagem com EMTN (p=0,01). CONCLUSÃO: há falhas na educação médica. Apenas 13,3% estavam seguros quanto à TN, sendo que os seus conhecimentos não justificaram tal confiança. Não houve diferenças entre os acertos dos confiantes e não confiantes em TN na maioria dos assuntos. Destacaram-se melhores resultados no grupo que afirmou ser assistido por alguma EMTN. Baseando-se nos resultados, a indicação de melhores programas médicos educacionais deve ser objetivo para esta universidade.

Terapia nutricional; Nutrição em saúde pública; Corpo clínico hospitalar; Médicos; Conhecimentos, atitudes e prática em saúde

TEACHING

Surgeons' knowledge and attitude regarding concepts of nutritional therapy

Danilo Andriatti Paulo^I; Bruno Mauricio Rodrigues de Oliveira^I; Davi Wei Ming Wang^I; Maysa Penteado Guimarães^II; Celso Cukier, ACBC-AM^III; Gaspar de Jesus Lopes Filho, TCBC-SP^IV

^IMedical School Graduate, EPM-UNIFESP

^IIVoluntary Physician, Discipline of Surgical Gastroenterology EPM-UNIFESP

^IIICollaborating Assistant Physician, Discipline of Surgical Gastroenterology, EPM-UNIFESP

^IVProfessor, Discipline of Surgical Gastroenterology, EPM-UNIFESP

Address correspondence to

ABSTRACT

OBJECTIVE: To compare the knowledge of nutritional therapy (NT) of surgery residents and surgeons.

METHODS: We applied two standardized questionnaires on knowledge, attitude and behavior regarding NT to 50 physicians (35 residents and 15 surgeons) of 12 different surgical areas. We compared the proportions of hits according to the perception on the subject of each group using the Fisher exact test, with 5% significance and p < 0.05.

RESULTS: More than 80% did not feel safe regarding NT and 46% denied knowledge of the NT multidisciplinary team (NTMT). There was a higher percentage of correct answers among residents in the items: surgical trauma and its nutritional influence on the patient (p = 0.047); normal BMI (p = 0.036); preoperative NT (p = 0.007); and indication of preoperative NT in the group that referred that to interact with the NTMT (p = 0.02). Among surgeons: complications of NT and NT in previously malnourished patients (p = 0.044); and methods for assessing preoperative nutritional status in the group that referred to interact with the NTMT (p =0.01).

CONCLUSION: there are gaps in medical education. Only 13.3% were confident about NT, and their knowledge did not justify such confidence. There were no differences between the successes of confident and non-confident about NT in most subjects. The best results came from the group that claimed to be assisted by any NTMT. Better medical educational programs should be goal for this university.

Key words: Nutritional Therapy. Public health nutrition. Hospital clinical staff. Physicians. Knowledge, attitudes and practice of healthcare.

INTRODUCTION

Hospital malnutrition has a direct impact on increased morbidity and mortality, the patient's nutritional status being an independent factor influencing surgical outcome^1,2.

In Brazil the overall incidence of hospital malnutrition is almost 50% in patients admitted to hospitals in the National Health System (SUS), while 12.6% are severely malnourished patients and 35.5% are moderate. This percentage is higher in the North and Northeast regions and lower in the South and Southeastern³. In the UK, it is estimated that more than 40% of patients are malnourished on admission and approximately two-thirds lose weight throughout their hospitalization⁴. This high prevalence of malnutrition can be even greater when compared to statistics of surgical gastroenterology, whose figures in the preoperative hospitalization reach 65%^5,6.

Malnutrition in surgical patients deserves special attention, as early diagnosis and nutritional treatment in the pre- and postoperative periods may determine substantive differences in management and prognosis⁷. The presence of noninfectious complications such as dehiscence and abdominal fistulas, and infectious ones such as surgical wound infections, can be influenced by nutritional status. This fact determines the importance of nutritional diagnosis still in the pre-operative period^8,9.

Malnutrition in surgical patients should focus on the state of the various components of body cell mass, as fat, skin, bone, muscle and protein, according to parameters based on clinical signs, food history, anthropometric and biochemical tests. In all known methods applied, the diagnosis is usually fast and effective, providing opportunities for nutritional intervention and subsequent correlation in reducing morbidity and mortality^2,3.

The subjective global assessment, described by Detsky et al., can only take a few minutes to be prepared, assessing weight loss, gastrointestinal symptoms and the disease in question, not requiring the use of large financial or technological resources^10,11. In a multicenter study, Correia et al. observed that despite the easiness of the nutritional assessment, it was rarely done. Patients were not weighted, for example, although there were scales at less than 50 meters from the bed, and there was no reference to nutritional status in medical records^3,12.

Several are the factors for the lack of nutritional diagnosis. Among them stands the small concern with teaching the subject in undergraduate and postgraduate levels^13-15.

It is known that there is no formal, specific nutritional training during residency in surgery, and in our country, there are no available studies which investigate the medical knowledge in this area, which justifies the development of research protocols^13-15.

The aim of this study was to determine the perception of knowledge and compare it with the degree of knowledge of the fundamental principles of nutritional therapy in surgery residents and surgeons.

METHODS

This study was conducted in the surgical wards of the São Paulo Hospital, university hospital managed by the Paulista Association of Medical Development (SPDM) and the Paulista School of Medicine Federal University of São Paulo (EPM-UNIFESP) under number CEP - UNIFESP / EPM 0953 / 10, and supported by FAPESP 2010/17964-4 and ESPEN 11-1779.

Participants

We interviewed surgery residents and Surgeons of EPM-UNIFESP, distributed according to the periods of residence in different specialties. They were addressed in the form of individual interviews, lasting approximately 15 minutes.

Intervention

Participants were assessed using two standardized questionnaires. The questions of the first questionnaire (Annex 1) sought to assess the degree of knowledge of fundamental principles in therapy and were based on guidelines for nutrition therapy in surgery developed by the Brazilian Society of Enteral and Parenteral Nutrition and also on the work of Awad et al.¹⁵. Participants were not aware beforehand that they would be evaluated, and answered questions without any support material and without discussing the issues with other professionals. Participants in the second questionnaire were asked to answer questions about their attitudes and behaviors regarding nutritional therapy (Annex 2), adapted from Awad et al.¹⁵.

Statistical Analysis

We verified if there was significant difference in the proportion of correct items on nutrition knowledge of the interest groups, divided according to the perception of knowledge on same subject. For the comparisons, we used the Fisher exact test; we considered a significance level of 5%. Thus, difference between groups was considered with a p-value < 0.05.

Expected Impacts

Relying on Awad et al.¹⁵, we expected to achieve an approximate number of 50-60 participants, evenly distributed according to the periods of residence. Among physicians, it was expected that less than half would answer as having adequate knowledge about nutritional therapy, more than half would state that rarely have to decide on nutritional therapy, and less than a quarter would feel able to calculate the daily energy and nutritional needs of the patients. It was also expected that more than 90% would agree that an adequate nutritional support would be essential to achieve good clinical and surgical results and that more than 40% would know of the existence of guidelines on nutritional therapy, and of these, only 10% would consult them. It was also expected that more than 70% would regard themselves as being able to identify patients at risk for malnutrition, but only 30% of these should have filled out the questions on the subject correctly. And finally, one would expect that more than 95% agreed that nutritional therapy training during residence would be valuable for the formation of the surgeon.

RESULTS

This study interviewed 50 physicians from 12 different surgical areas of EPM-UNIFESP. Thirty-five were residents and 15 surgeons.

Residents were distributed among the first four years of residency, the majority belonging to the second (31.4%) and third (40%) years (Table 1), and surgeons, according to their specialty (Table 2.)

In the analysis of responses to the questionnaire on perception of nutritional therapy (Annex 2), we observed that over 80% of the participants did not feel secure confident towards nutritional therapy (Table 3). Also, we recorded 74% of respondents without the support of the Nutrition Therapy Multidisciplinary Team (EMTN), 46% of which being unaware of the existence of an EMTN in their services (Table 4).

By generically analyzing the hits and errors of the questionnaire on general knowledge about nutrition (Annex 1), it was revealed that in 38% of the questions the percentage of correct answers was less than 50% and in only 14.2% of the questions there was a success rate above 75%.

When analyzing the data from the questionnaire on nutritional knowledge (Annex 1) and the one about perception in nutrition (Annex 2), as for residents, there was a higher percentage of correct answers in relation to operative trauma and its influence on the metabolic and nutritional status of the patient in the group who claimed not to have adequate knowledge of nutrition therapy in surgical patients (p = 0.047); of BMI considered normal for the eutrophic patient in the group agreeing on regularly deciding on therapy and nutritional interventions of patients (p = 0.036); of preoperative NT in the group that agreed on feeling that training in nutritional therapy would be valuable for the surgical career (p = 0.007); and of indicating nutritional therapy (NT) in a surgical patient in the group that claimed to interact with EMTN in some cases (p = 0.02).

Among surgeons, that there was a higher percentage of correct answers in: complications of enteral nutrition therapy and NT in previously malnourished patients in the group that agreed to have adequate knowledge and skills to identify patients at risk of malnutrition (p = 0.044); methods of preoperative nutritional assessment in the group agreeing on feeling that training in nutritional therapy would be valuable for the surgical career (p = 0.056); and methods of preoperative nutritional assessment in the group claiming to interact with the EMTN in some cases (p = 0.01).

DISCUSSION

The UK National Institute for Health and Clinical Excellence (NICE), and independent British organization responsible for providing guidance on promotion and prevention in public health in the UK, and the Brazilian Society of Parenteral and Enteral Nutrition (SBNPE) recommend that any member of the health team should receive education and training on nutritional therapy during their professional formation^3,15,16. It is known that medical surgical teams can often consult with the nutrition expert. However, not all hospitals have them. It is expected that the surgical staff know, fully and effectively, how to offer proper nutritional therapy for any surgical patient¹⁵.

In contrast to the recommended, our study showed that there are gaps in medical education, since more than 80% of surveyed medical residents were not confident about the nutritional therapy for their patients and that more than 50% knew a few questions about the knowledge on this area. These data are in partial agreement with previous British publications, which shows the deficiency of medical education in countries unlike Brazil in medicine¹⁵.

Based on this literature, it was expected that well over 70% of the respondents of this study would deem themselves capable of identifying patients at risk of malnutrition. Nonetheless, we showed that only 14% claimed that knowledge. It was also expected that more than 40% knew the NT guidelines available in the medical literature, but only 6% answered they had it. These data further corroborate the conclusion about the low value of medical education in NT.

It is also known that there are negative effects on the general state of the operated patient when there is a low level of knowledge on the medical nutritional therapy by doctors⁷, and yet 13.3% of respondents were sure about their skills in the subject. The results of their knowledge did not justify such certainty though, since there was no greater success rate in this group with statistical significance for most subjects.

Awad et al. drew attention to the need for educational programs in nutrition in British medical training by showing that the lack of knowledge about the subject was present in both groups¹⁵. Our results and conclusions are similar, because there were no statistically significant differences between the successes of both groups, nor were there any differences between the results regarding the perception of NT in both countries.

It is noteworthy that there was a greater number of hits on indications of nutritional therapy in surgical patients and methods of professional preoperative evaluation in the groups of residents and surgeons who claim to be assisted by any EMTN, which can point to the efficacy of such services in medicine. It is known that the presence of an EMTN in a service improves nutritional supply, reducing the incidence of complications and cost. It can therefore be inferred that the presence of an EMTN enriches the content of clinical discussions¹⁷. However, we found that 46% of participants are unaware of these teams in their institutions.

We also noted that the subject trauma displayed a better sedimentation of nutritional issues among residents. We attribute this to the great historical participation of this sector in the areas of surgical expertise and its comorbidities. Also, we observed that the subject BMI in the same group had more hits, since it is the most respected nutritional index in medical practice. Nevertheless, we emphasize that the use of the subjective global assessment of Detsky et al. yields a better assessment as to weight loss, gastrointestinal symptoms and severity of the disease, and should therefore be sedimented in medical education^10,11.

Among surgeons, the topics complications of enteral nutritional therapy and nutritional therapy in previously malnourished patients were detected in groups that considered themselves as having good knowledge about NT. We inferred that the greater experience of these surgeons in the medical practice made them more insightful about perioperative complications, typically observed in the malnourished patient.

Based on the data observed in the questionnaires and on the necessity of making decisions about nutritional therapy, this study examined whether knowledge of surgery residents and surgeons is appropriate. The result point to the importance, for the formation of the surgeon, of an establishment of educational programs, workshops and better access to the specific literature^18-22.

In conclusion, there are gaps in medical education. Only 13.3% were confident about NT, and their knowledge did not justify such confidence. There were no differences between the successes of NT confident and non-confident in most items assessed. Better results were obtained from the group that claimed to be assisted by any EMTN. Better medical educational programs should be goals for this university.

REFERENCES

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Publication Dates

• Publication in this collection
  09 Jan 2014
• Date of issue
  Oct 2013

History

• Received
  10 July 2012
• Accepted
  20 Sept 2012