Surgical Practice: Evidence or Anecdote

Objectives

Our objective is to highlight a few surgical practices that are not based on evidence but are still taught in surgical education, and to assess our experience with these practices.

Design

We identified 3 practices (clamping of nasogastric tubes before removal, bowel preparation before elective colon resection, and elective sigmoid colectomy following 2 bouts of diverticulitis), identified the data supporting each practice, and administered a survey to faculty and residents at our institution.

Setting

Wright State University Department of Surgery, Boonshoft School of Medicine, Dayton, Ohio.

Participants

Twenty-one faculty and 35 residents responded to the survey.

Results

No studies were found relating to clamping nasogastric tubes before removal. Seven faculty (33%) and 11 residents (31%) used this practice. Two faculty (10%) and 0 residents felt this was an evidence-based practice. Faculty were more likely to have reviewed the evidence (85% vs 40%, p < 0.001). Level 2 evidence has shown bowel preparation did not improve outcomes relating to anastomotic leak, wound infection, or septic complications in elective colon resection. Twenty faculty (95%) and 34 residents (97%) used this practice. Faculty were more likely to believe this to be evidence-based (85% vs 49%, p = 0.01). There has been no level 1 or 2 evidence showing that sigmoid colectomy following 2 bouts of diverticulitis improves morbidity or mortality. Fourteen faculty (70%) and 26 residents (76%) reported using this practice. Twelve faculty (60%) and 21 residents (60%) felt this was evidence-based.

Conclusions

Frequent use of surgical practices without evidence support can create a misperception that such practices are evidence-based. Faculty are more likely to change a practice after obtaining continuing medical education, suggesting that residents may need validation by faculty practice of evidence-based procedures before incorporation into their clinical care.

Key Words: diverticulitis, evidence-based medicine, mechanical bowel preparation, nasogastric tube, surgical education

Competencies: Medical Knowledge, Practice-Based Learning and Improvement, Systems-Based Practice