Building a Better Pre-Op Visit

\r\nHe has published in several medical journals, including recent research on use disparities in telehealth visits & effective community outreach interventions to encourage COVID vaccination. His weekly MedPage Today column, \u201cBuilding the Patient-Centered Medical Home,\u201d focuses on improving patient care.<\/p>“,”affiliation”:””,”credential”:”MD”,”url_identifier”:”fp4223″,”avatar_url”:”https:\/\/assets.medpagetoday.net\/media\/images\/author\/Pelzman_330px.png”,”avatar_alt_text”:”Fred Pelzman”,”twitter”:””,”links”:null,”has_author_page”:1,”byline”:”Contributing Writer, MedPage Today”,”full_name”:”Fred Pelzman”,”title”:”Contributing Writer, MedPage Today, “,”url”:”https:\/\/www.medpagetoday.com\/people\/fp4223\/fred-pelzman”,”bluesky”:””}]”/>

Every week, seemingly every day, peppered through all of our schedules are appointments labeled “preoperative evaluation.”

These are patients referred to us, their primary care doctors, by surgeons within our institution and outside, who have some sort of upcoming procedure planned.

Sometimes the conversation goes well, the patient is followed by a specialist within our institution, their notes are available for us to see, and we know what’s being planned, and even what preoperative testing is required.

Every once in a while, however, we get a patient who says, “I’m having some sort of surgery by some doctor, I can’t remember their name. They told me to see you and get medical clearance, and said that I needed some testing, but I can’t remember what the surgery is, or what it’s for, or what type of anesthesia they will be using. And it hasn’t even been scheduled yet; they told me once you cleared me then they’d be able to schedule it. Oh, and by the way, I forgot the form.”

The first kind of visit usually goes pretty smoothly. We all can use the risk calculators for pre-op assessments; help our surgical colleagues figure out whether a patient’s medical conditions are optimized; whether they need some other interventions, such as stopping a medicine, starting a medicine, avoiding an herb or supplement, or even having more intensive evaluations of their cardiometabolic state for high risk surgical procedures.

Years ago, one of my mentors, an esteemed cardiologist, told me that ultimately, surgeons and anesthesiologists “clear” their patients for surgery, and it is our job to help them understand the state of the patient’s current medical conditions and whether they’re going to be able to handle the surgery, or whether it might be too risky to proceed.

Sometimes, on a preoperative form that the patient brings with them, they have a little box they want us to check that says, “This patient has been medically cleared for surgery”.

It’s one of my long-standing sticking points that I don’t check this box. But I’m happy to write, as I do in my assessment and plan, that the patient’s medical conditions are optimized, and that no additional preoperative interventions are warranted at the present time. Or if there are any, what they are, and what conditions need to be met for the patient to safely proceed with the best chance for a good outcome.

If the surgery hasn’t even been scheduled, or we don’t even know what the operation is going to be, there’s no way we can really comment.

Some of the best preoperative interventions I’ve done for patients have involved great communication with their surgeons, where they asked me questions, I asked them questions, we talk about the patient, and we come to a consensus.

For us, it should never really just be about checking a box.

More often than not, preoperative labs and EKGs don’t really do that much for us — or the patient or the surgeon or the anesthesiologist. These tests rarely provide much useful information that will change how the surgery will go.

Checking the prothrombin time/partial thromboplastin time (PT/PTT), for a patient who is not on anticoagulation and doesn’t tell you in their history that they have severe easy bleeding or bruising, doesn’t have a known coagulopathy, and aren’t on long-term anticoagulation, rarely changes our course of management.

Years ago, the anesthesiologists who assisted our ophthalmology teams required extensive pre-op labs and EKGs in advance for cataract surgery.

We always questioned why these tests were necessary, and eventually, after a lot of communication and discussion, everybody decided it was not really necessary, that everyone had always assumed that everyone else wanted to see these results. So now, all preoperative testing is left to the discretion of the person providing medical clearance, the surgeon and the primary care doctor and the anesthesiologist.

To make better use of everybody’s time, it would be great if we could develop a system to make things go smoother in the world of preoperative evaluation, for everyone involved.

Anyone trying to schedule this type of appointment should be required to have certain things submitted in advance by the surgeon, including the date of the surgery, the risk of the surgery, the type of anesthesia planned, what medications they do not want patients to be on for the surgery, and what their questions are about this patient that prompted them to be sent to us.

Just because a patient is of a certain age, or has a couple chronic medical conditions, doesn’t mean they automatically have an increased risk of cardiopulmonary or other complications from surgeries.

But often we can help, often we can guide the patients and the surgeons and the anesthesiologists, make useful suggestions that can make things go smoother, both during the surgery and in the hours and days afterwards.

As we continue to improve things within our electronic medical record, data for the preoperative assessment can be collected in advance, necessary testing can be pre-ordered and loaded up, and all the necessary preoperative calculations could already be calculated by the time we see the patient.

Our office note, once completed, would suffice. One of my other long-standing policies is I don’t copy over my office note by hand onto some paper form that another doctor’s office provides for me — all the information they need is right there in my preoperative visit note.

And if something isn’t in there, if something is unclear, they can certainly pick up the phone and call me and ask me a question.

Clear?

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