Struggling with Surgeons: A Dietitian's Tale

Let me start by saying that surgeons play an incredibly important role in the medical community. They remove tumors, perform complex procedures, and dedicate countless hours and years of their lives to their profession. On a personal note, multiple members of my family would not be alive today without the incredible work of surgeons. I really can’t thank these individuals enough for taking the risk of opening a human body and the mental and physical toll that their job faces.

That’s my ode to surgeons.

Now on to the criticism.

As a dietitian, my most frustrating encounters are with surgeons. Recently I was following a frail, elderly patient status post-surgery with a G-tube placed for tube feeds. Although she was started on an oral diet, she was eating about 10% of her meals. The appropriate intervention in this situation was to have the enteral nutrition provide the majority of her calorie/protein needs and then wean down and discontinue the nutrition support as her appetite/intake improved.

Surgery saw it differently.

In the weeks (weeks!) after her surgery, surgery refused to allow us to advance much

past trickle feeds which provided only a few hundred calories. They also continued to document that her intake was improving although it very clearly was not. Additionally, although nutrition support is essential in any person, this was a person who was likely moderately malnourished prior to surgery so she can’t afford to lose much ground nutrition-wise.

I don’t understand why the surgeons have such difficulty approving nutrition support. It almost seemed from their notes that they had this false optimism of her intake improving coupled with a blind eye towards her present situation. That’s common in the families of patients. It should not be common in surgeons.

Nutrition and Surgical Outcomes

On a more general note, surgeons tend to make nutrition the last priority. However, we know that nutrition plays an essential role in preparing for surgery and recovery afterwards. Traditionally, any elective surgery had patients fast before surgery and didn’t introduce a diet until 3-5 days after surgery. More recent studies have indicated that improving the nutrition status of patients before surgery and early feeding after surgery can reduce length of stay. Just for cost alone, it’s worth taking a second look at how we deal with nutrition guidelines around surgery. Some additional studies have also shown a trend towards reducing the risk of sepsis and post-op complications.

Why the Pushback?

My colleagues and I discuss advancing diets with surgeons but we usually don’t get very far. Since surgeons tend to not want to discuss their reasoning with us much of

the time, it’s difficult to pin down why they don’t want to advance diets. Older surgeons will often wait until bowel function has returned but most of our surgeons are younger. I don’t think their motivation is a power struggle either. I have seen that be the case in my first hospital although, once again, not where I’m currently working.

Moving Forward

One of the problems that we face as dietitians in the hospital is that most physicians have little to no nutrition training. It would be great if doctors had to take a basic nutrition class in medical school, but I don’t have the ability to mandate that.

At present, our team of dietitians are facing this problem by trying to have these conversations with our surgeons. I like to think that persistence may be our saving grace. It takes time to change habits and, faced with evidence over time, I hope that our surgeons will be more willing to be more aggressive with nutrition. That’s my take anyways.