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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 8-11

Back to basics – The importance of enterostomal therapy education for general surgery residents


Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA

Date of Web Publication30-Aug-2018

Correspondence Address:
John J Tackett
Yale University School of Medicine, New Haven, Connecticut
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1941-8213.240253

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  Abstract 


Background and Objectives: General surgery residents' perceived knowledge base and comfort with intestinal stomas and enterostomal therapy are profiled through a national survey. Subjects and Methods: General surgery residents were surveyed to explore the existence of formal didactics and training in ostomy creation and stomal care, to examine the residents' perceived knowledge base of clinical indications for enterostomal care approaches, and to elicit the residents' comfort with performing enterostomal surgeries and managing complications. Results: A total of 734 US residents were surveyed. 218 respondents completed the survey (30%): 40% Northeast, 22% Midwest, 22% South, 16% West, and 82% with direct university affiliation. Only 12% experienced formal enterostomal therapy training and only 15% attended related lectures. Most (86%) routinely worked with enterostomal therapists. Only 11% of chiefs felt “very confident” in their knowledge base of clinical indications for enterostomal care, and 61% felt “very comfortable” with surgical procedures of ostomy creation and closure. Merely 4% of all residents felt “very comfortable” dealing with common ostomy complications. Conclusions: In an era of surgical subspecialization and advanced nursing practice in enterostomal therapy, general surgery residents lack confidence in their knowledge base and comfort when approaching enterostomal therapy and stomal complications. US resident education should be reformed to enhance training in these fundamental principles essential to general surgery practice.

Keywords: Education, enterostomal therapist, ostomy


How to cite this article:
Tackett JJ, Fonseca AL, Longo WE. Back to basics – The importance of enterostomal therapy education for general surgery residents. World J Colorectal Surg 2018;7:8-11

How to cite this URL:
Tackett JJ, Fonseca AL, Longo WE. Back to basics – The importance of enterostomal therapy education for general surgery residents. World J Colorectal Surg [serial online] 2018 [cited 2019 Aug 18];7:8-11. Available from: http://www.wjcs.us.com/text.asp?2018/7/1/8/240253




  Introduction Top


Over a half million people in the United States are living with some type of functional enterostomy and surgeons create approximately 120,000 annually.[1] In most large centers, including many teaching hospitals, these ostomies are comanaged with an enterostomal therapist. An enterostomal therapist is a nurse who specializes in the care of patients before, during, and after creation of an ostomy. The concept of enterostomal therapy is almost 60 years old, but as the practice becomes more popular in healthcare systems, surgical residents are often left out of this formalized and specialized medical training.

In 1952, Dr. Albert S. Lyons, a surgeon and prominent leader in ostomy care, wrote about a club of patients at Mt. Sinai with ileostomies who would meet with each other, as well as with physicians and nurses, to discuss and improve on their ostomy care.[2] By 1960, Mt. Sinai had a successful special rehabilitation clinic dedicated to ostomy care.[3] Simultaneously, at the Cleveland Clinic, the colorectal surgeon, Dr. Rupert B. Turnbull Jr., was enlisting the help of his former patient Norma Gill as a stoma technician. Before Gill volunteered her services for patient care and education, Turnbull was focused on educating his surgical colleagues in proper ostomy care through symposium and scientific journals.[4] By 1958, Dr. Turnbull had trained Ms. Norma Gill as the first “enterostomal therapist,” and by 1961, they had established the first enterostomal therapy training program in the United States.[5] Dr. Henry Finch later described an enterostomal therapist as someone “trained to provide preoperative consultation to the patient, postoperative care of the stoma and equipment (…and) instruction in hospital and follow-up care.”[6] Since then, more and more enterostomal therapists around the world have been trained to specialize in ostomy therapy and contemporary complex wound care. Concurrent with the growth in the field of training enterostomal therapists, there have been changes in US general surgery residency training.

Over the past decades, the breadth of surgical training has changed significantly. With the advent of new technology, increasing complexity of disease, significant loss of autonomy, and duty hour work restrictions, many think the general surgeon of today is different from that of years passed.[7] With changes in healthcare systems and medical education, there has been a more focused early specialization in surgical training. Some of this early specialization in training comes in the form of integrated subspecialty training, such as cardiothoracic surgery and vascular surgery, which were once capstone fellowships after a general surgery residency.[7] However, some changes also come by way of surgical trainees focusing on the crucial operative and clinical skills of surgical patient care without duplicating efforts of other specialists on the healthcare team, specialists like enterostomal therapists.

This work aimed to evaluate whether the basics of enterostomal care have been lost in the education of general surgery residents during a time of well-trained enterostomal therapist involvement and focused efficient general surgery training.


  Subjects and Methods Top


Study design and sample population

In 2015, an anonymous survey was distributed to 734 US general surgery residents through permission of their residency program directors. An informative introduction indicating that participation was voluntary and ensuring confidentiality was provided with each survey. Completion of the survey constituted implied consent. The Human Investigation Committee at the Yale University School of Medicine approved the research protocol for exemption.

Survey instrument

To appropriately construct the survey, we used a multistage approach that has previously been validated as a technique for developing qualitative survey tools. The first stage used open-ended interviews to identify the factors that colorectal surgeons felt were important involving enterostomal therapy. We interviewed both junior and senior colorectal surgery faculty. None of the individuals contacted refused to participate.

We conducted in-depth interviews to generate narrative data regarding operative and clinical enterostomal care as well as complication management. We interviewed attendings until no new concepts were discussed in additional interviews. This occurred after three interviews. The interviews investigated important education and training concepts in enterostomal therapy using open-ended questions such as, “what do you feel are certain enterostomal therapy indications and complication that residents should feel comfortable managing?” and “what concepts do you think residents are missing in enterostomal therapy now that enterostomal therapists are commonly involved in patient care?” The interviews were transcribed, and themes were identified and coded. The research team identified recurrent concepts that described the expected knowledge base for clinical indications for enterostomal care approaches and enterostomal surgeries and associated complications that residents should feel comfortable managing upon completion of a general surgery residency.

Based on these themes, a survey of five demographic questions, five direct presence or absence of education/training experience questions, and fifteen statements of perceived confidence in knowledge base or comfort with clinical/operative management measured on Likert scale was developed [Appendix 1]. The survey was piloted with ten residents across the five clinical training years at the research team's home institution. Revisions were made based on feedback of the pilot participants. The resident respondents noted the presence or absence of education/training experiences with a simple Yes or No. They agreed with each statement about perceived strength of knowledge base on a 5-point Likert response scale ranging from “completely confident” to “completely unsure.” They agreed with each statement about comfort with matters of clinical/operative management on a 4-point Likert response scale ranging from “very comfortable” to “very uncomfortable.” Surveys were performed anonymously, but they included the classification of postgraduate year in training, regional location of training program, presence of University affiliation of the training program, presence of a dedicated colorectal rotation, and presence of enterostomal therapists on the care team.



Data analysis

Descriptive statistics were used to illustrate the current state of enterostomal education in US general surgery residency program. Statistical significance was evaluated on agreement Likert response statements by applying Fisher's exact test to the measure of difference between levels of agreement. Statistical significance was defined as P < 0.05, and confidence intervals were defined as 95%. Analyses were conducted using Prism software, (version 6c, GraphPad Software, Inc, La Jolla, CA, USA).


  Results Top


Respondents

A total of 734 US residents were surveyed across the country by permission of their program directors. 218 respondents completed the survey (30%). The geographical distribution of the respondents programs were in the following regions: 40% Northeast, 22% Midwest, 22% South, and 16% West. The respondents were all in ACGME accredited general surgery residency programs, with 82% recognizing a direct university affiliation. The class makeup of respondents was as follows: 24% interns, 23% PGY2, 17% PGY3, 10% PGY4, 10% PGY5 surgical chiefs, and 17% research residents. Only 12% of respondents stated that they experienced formal enterostomal therapy training, and only 15% had attended lectures specifically dedicated to enterostomal operations, complications, and therapies. Most respondents (86%) routinely worked with enterostomal therapists.

Survey responses

As a whole group of all respondents, the residents were neither comfortable with their knowledge base nor confident in their ability to perform enterostomal operations and manage enterostomal complications. Despite preparation for written examinations and didactic curriculum, only 3% of all residents felt “completely confident” in their knowledge base of clinical indications for enterostomal care [Table 1]. While no questions specifically asked about resident case logs, only 14% of all resident respondents felt “very comfortable” with surgical procedures involving ostomy creation and closure. When facing the complications of ostomies, a mere 4% of all residents felt “very comfortable” managing those patients [Table 2].
Table 1: Percentage of respondents by postgraduate year of training and as a whole group who stated they were “Completely Confident” in their knowledge base of clinical indications for enterostomal care

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Table 2: Percentage of respondents by postgraduate year of training and as a whole group who stated they were “Very Comfortable” managing patients with common ostomy complications

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With graduating US general surgery chief residents representing the current “final product” of general surgery training, only 11% felt “completely confident” in their knowledge base of clinical indications for enterostomal care. Slightly more than half of the chiefs, at 61%, felt “very comfortable” with surgical procedures of ostomy creation and closure. Despite 5 years of clinical training, only 15% of graduating chiefs felt “very comfortable” dealing with common ostomy complications.


  Discussion Top


Enterostomal therapists serve as liaisons between physicians and patients with ostomies requiring specialized care.[8] Involvement of an enterostomal therapist in the preoperative and postoperative care of patient with an ostomy has demonstrated a reduction in adverse outcomes related to the ostomy.[8] Since the major advances of ostomy surgery in the 1950s and 1960's, much of the subsequent ostomy care research has been driven by enterostomal therapists.[9] This evidence-based specialized ostomy care has improved outcomes for patients, but simultaneously removed some of the responsibility of ostomy management out of the hands of surgeons. Along with a shift in ostomy care management from surgeons to enterostomal therapists, there is a vacancy in the education of surgeons-in-training to understand not only how to create and reverse ostomies but also how to manage them pre-and post-operatively.

The results of this survey demonstrate the lack of formalized ostomy education among US general surgery residents. Although ostomy surgery is a basic operation for a general surgeon, many surgical residents are graduating without the operative confidence or proper knowledge base to care for this group of patients. Many centers have become so reliant on enterostomal therapists that residents miss out on opportunities to be involved in stomal care. This lack of knowledge requires a dependence on the services of an enterostomal therapist in order to provide proper patient care. In addition, this loss of educational opportunities takes young surgeons out of the leadership role in total patient care.

Formalized education in stomal surgeries and therapy can attempt to remedy this perceived lack of confidence and knowledge base while restoring the surgeon as the lead manager in the care of a patient with an ostomy. A focused curriculum in ostomy management led by colorectal, general, and trauma surgeons working with enterostomal therapists could provide a solid knowledge base for residents during their surgical didactics. Involving the enterostomal therapists in the education process simultaneously enhances physician training and builds collegiality that can be transferrable to future practice involving enterostomal therapists.


  Conclusions Top


In an era of surgical subspecialization and advanced nursing practice in enterostomal therapy, general surgery residents lack confidence in their knowledge base and comfort when approaching enterostomal therapy and stomal complications. Resident education across the country should be reformed to enhance training in these fundamental principles essential to general surgery practice.

Acknowledgment

The authors would like to thank Mr. Adam Wallenfang for his help in proofreading and editing the article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
United Ostomy Associations of America I. Living with an Ostomy. Kennebunk, ME: UOAA; 2005-2018.  Back to cited text no. 1
    
2.
Lyons AS. An ileostomy club. JAMA1952;150:812-3.  Back to cited text no. 2
    
3.
Lyons AS, Schreiber G. The special rehabilitation clinic of Mt. Sinai Hospital. Ileostomy Quaterly 1960;4:4-5.  Back to cited text no. 3
    
4.
Turnbull RB Jr. Management of the ileostomy. Am J Surg 1953;86:617-24.  Back to cited text no. 4
    
5.
Benfield JR, Fowler E, Barrett PV. Enterostomal therapy. Arch Surg 1973;107:62-5.  Back to cited text no. 5
    
6.
Finch HM. Enterostomal therapy – A new approach to ostomy care. J Med Assoc Ga 1970;59:299-300.  Back to cited text no. 6
    
7.
Longo WE, Sumpio B, Duffy A, Seashore J, Udelsman R. Early specialization in surgery: The new frontier. Yale J Biol Med 2008;81:187-91.  Back to cited text no. 7
    
8.
Bass EM, Del Pino A, Tan A, Pearl RK, Orsay CP, Abcarian H, et al. Does preoperative stoma marking and education by the enterostomal therapist affect outcome? Dis Colon Rectum 1997;40:440-2.  Back to cited text no. 8
    
9.
Turnbull GB, Erwin-Toth P. Ostomy care: Foundation for teaching and practice. Ostomy Wound Manage 1999;45:23S-30S.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2]



 

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Abstract
Introduction
Subjects and Methods
Results
Discussion
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