I’m Sorry, But I Can’t “Clear” Your Patient


 
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By Michael McCutchen, MD

Every primary care provider has been there. A patient comes in requesting a pre-operative evaluation or places a phone call or EMR message expressing the need for “clearance” before having a surgical procedure. Sometimes, we even get a request from the surgeon’s office with paperwork for “clearance.”

Time is always, seemingly, of the essence regarding these evaluations, and either the patient or the operating surgeon requests this be done expediently to schedule a procedure or proceed with one already scheduled. All primary care providers know that the fecal matter of medical paperwork tends to roll downhill.

Whether it is a request for FMLA, disability, or medical clearance, as suggested above, these tasks are typically always pushed to the primary care provider. Why? I do not know, maybe because we know the patient best. Or perhaps because we continue to be reluctantly willing to do it.

With regard to operative clearance, maybe we live in a very medically litigious society, and it makes sense to diffuse perioperative risk over multiple providers. The real reason I do not know. The one thing I do know is that I cannot “medically clear” your patient for surgery.

It is commonly addressed among family physicians/internists, anesthesiologists, and cardiologists that “medical clearance” is a misnomer. The pre-operative evaluation attempts to mitigate the chance of pre-operative and post-operative complications of surgery. It involves a detailed history, physical exam, and chart review to determine a patient’s risk of an adverse event or complication resulting from anesthesia or surgery.

This evaluation is necessary. However, the terminology and expectations need to change regarding the information the examining physician can provide. The purpose of the pre-operative assessment is to identify and mitigate risk and give the patient and the operating physician a clear view of the risk being undertaken by both the patient and the operating physician.

All too often, I am sent the pre-operative exam form and find at the bottom: “I, (state your name), deem this patient to be medically cleared for (insert surgical procedure.” Under this statement, a signature of the evaluating physician is requested, thus welcoming myself into being liable for operative complications. Saying a patient is “medically cleared” for surgery implies they are risk-free and in no danger of complications when no provider can confidently make that call.

Until the expectations placed on primary physicians become more distinct and reasonable, I will continue to avoid the term “medical clearance” with regard to the pre-operative evaluation. I will, instead, amend every form to delineate the patient’s level of operative risk and provide avenues of improving risk that can be sought before the performance of the procedure.

Michael McCutchen is a family physician.


 
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Comments:

  • I'm quite encouraged to know you will abandon the term "clearance," as that word insinuates that it is the internist who makes the final decision as to whether the patient is ready for surgery and anesthesia. In fact, it is the case that the preanesthesia evaluation-- of which the preoperative medical assessment (POMA) serves as a COMPONENT-- should outline if the patient status has been optimized so as to withstand the rigors of anesthetic medications (IV, IM, IO and inhalational), the likely imbalances in intravascular volume status and even the temperature changes that typically accompany a standard anesthetic. The goal of the POMA is to provide a risk assessment of how well the patient will tolerate a surgical procedure; the surgeon and anesthesiologist will then tailor the perioperative management of the patient to mitigate that risk and subsequently avoid any potential morbidity. Unfortunately, the surgeon repeatedly holds in higher esteem the POMA offered by the non-anesthesiologist. So many times the surgeon will "weaponize" the "clearance," as s/he announces "but the 'clearance' says..." or "the patient was 'cleared'..." regardless of the quality of said evaluation. Oh, how maddening it is to see, written on a prescription pad no less, "patient is cleared", and the surgeon will regard this document as holding sway above the clinical expertise of the anesthesiologist. What is even more infuriating is the internist going so far as to declare what type of anesthesia the patient receive. Once, an internist wrote "patient must NOT be intubated", because of advanced COPD; I invite any internist to join the surgical team in the operating room to observe how well a non-intubated patient will fare undergoing general anesthesia for an exploratory laparotomy without being intubated (and yes, I sure will "avoid hypotension"!). Once the surgeon or proceduralist accepts that it is the ANESTHESIOLOGIST who "clears" the patient and determines the disposition of the patient, the better will the patient fare and the better the operative team will serve the patient. The anesthesiologist welcomes the input of the internist as a valuable component of a useful preanesthetic assessment, but its primary purpose remains as an important adjunct in determining the complete optimization of the surgical patient. "I am the one who clears!" said the anesthesiologist.

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