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Pre-Operative Evaluation: Don't Call it a Clearance

By Molly Adrian, JD, Legal Risk Management Consultant at Mutual Insurance Company of Arizona (MICA)

From Print Issue- Fall 2023
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As a primary care physician or advanced health care professional (AHCP) treating patients for various health conditions, you will likely encounter requests to “clear” patients for surgery. In this context, “clearance” means that the evaluating physician believes the patient is healthy enough to undergo surgery. This terminology, however, can be misleading to all involved — the patient, the doctor or AHCP, the surgeon, and a potential jury deciding a professional liability case. It diminishes the true nature of what should be accomplished during a pre-operative evaluation.



Dr. Fred Pelzman, an internal medicine doctor, states in a 2022 opinion piece on pre-operative evaluations that “collaboration is key, and so often communication is the thing that makes this work…when communica­tion and connection are lacking, collaborative patient care can suffer.” When a surgeon recognizes that a surgical candidate may have health factors that could pose a risk during surgery, or the patient’s health insurance plan requires a “clearance,” the surgeon will contact other members of the patient’s care team for a pre-operative evaluation.


Mutual Insurance Company of Arizona (MICA)'s Risk Team fields calls from PCPs, AHCPs, and specialists who relay that they have been asked to simply check a box that says “cleared for surgery” or to write a simple statement to that effect. These physicians and AHCPs express discomfort with doing so since the picture of the patient’s health is often more complex than that, but also feel pressured to move things along, especially when requiring a more in-depth evaluation could delay a procedure the patient so desperately wants or needs.


MICA recommends physicians and AHCPs discuss with the surgeon the need for more time for the PCP/AHCP, specialists, surgeon, and patient to engage in an appropriate risk/benefit analysis with consideration for the patient’s condition(s), the type of surgery, and the urgency of surgery. That process may include the following steps:


  • Call the surgeon to discuss the planned procedure.

  • What is the type and expected length of the procedure?

  • What kind of anesthesia will the patient need?

  • How long will the patient be confined to bed?

  • What type of rehabilitation is expected?

  • What is the anticipated recovery time?

  • What is the urgency of the procedure?

  • The evaluating practitioner should review the patient’s medical records and complete a physical examination and diagnostic testing, and, if necessary, refer the patient to a specialist(s) for additional pre-operative evaluation.

  • Upon completion of the pre-operative evaluation, the care team should communicate about whether the patient is healthy enough to proceed with surgery and if there are any reasonable and prudent steps the health care team should take to potentially improve the patient’s surgical outcome.

  • The surgeon and anesthesiologist should each have an informed consent discussion with the patient during which they share the risk/benefit analysis so that the patient may make a fully informed decision about whether to proceed and/or understands why the surgery may not be a good option at this time.


It may turn out that the patient is free of serious comorbidities and the surgical and anesthesia risks are low. A single phone call with the surgeon and documentation of your findings and thought process in those instances may suffice. In an emergency, with no time to complete these steps the surgeon and other members of the health care team should advise the patient or their representative of the risks of proceeding or waiting. In many cases, the patient will fall somewhere in between these two scenarios. In that case, it is worthwhile to engage in a pre-operative evaluation and to document your efforts to help the patient and the health care team proceed with a more complete picture of the patient’s health.


Facing the reality of undergoing surgery and the recovery process along with discussions with health care practitioners surrounding how lifestyle choices have contributed to the need for surgery and/or to greater potential for adverse outcomes may be an impetus for change. This could be an opportune time to discuss the benefits of and strategies for things like smoking cessation, weight loss, diabetes control, blood pressure control, and other lifestyle factors the patient may be willing to re-examine. Doing so, and documenting that you’ve done so, also demonstrates your genuine concern for the patient’s wellbeing and long-term health status.



As with all medical care, the evaluating practitioner(s) and surgeon face malpractice risk if an adverse event occurs during the procedure or recovery period. Ways to prevent malpractice allegations and fortify the defense of a malpractice lawsuit include the following:

  • Completing an appropriate pre-operative evaluation for the patient’s condition, type of procedure, and urgency of the procedure.

  • Engaging the patient in an informed consent process in which the surgeon and anesthesiologist explain the risks and benefits of, and alternatives to, the proposed procedure and type of anesthesia.

  • Trying to help the patient set and maintain reasonable expectations by explaining the possible outcomes of the procedure and what recovery might look like in the short- and long-term.

  • Documenting each patient encounter and all efforts to discover and mitigate potential risks of proceeding with surgery.


“Clearing” a patient for surgery is a broad term that may later be used to imply the PCP, specialist, or AHCP evaluated and considered factors and findings outside their area of expertise. Most PCPs, specialists, and AHCPs are instead “identifying and evaluating” patient’s medical problems and “recommending” interventions to address those problems within their scope of practice and in consideration of a surgery and/or anesthesia. “Pre-operative” evaluations give the health care team the opportunity to help prepare patients for optimal outcomes.

About the Author:

Molly Adrian, JD, is a Legal Risk Consultant with the Mutual Insurance Company of Arizona (MICA).  Prior to joining MICA, Molly practiced as an Assistant Attorney General working with various programs within the Arizona Department of Health Services, and later moved into private practice where she worked to defend healthcare practitioners and institutions from allegations of medical malpractice.  In her role as part of MICA’s risk management services department, she is committed to using her background and experience to provide MICA’s insured clients with sound risk management advice and resources to help foster quality patient care while minimizing liability exposure.

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