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

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.

 

COLLABORATION AND COMMUNICATION

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.

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• 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?

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• 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.