In preparation for my next day’s cases at the large academic medical center where I work, I reviewed a chart for a 90-year-old with severe spinal cord stenosis who was scheduled for extensive spine surgery to alleviate debilitating neurologic symptoms.
She suffered from a myotonic dystrophy and mild dementia. Her history was complicated by severe mitral regurgitation with severely elevated pulmonary artery pressures and a heart failure-related hospital admission the prior year, although she had not had an echocardiogram for nearly two years. Afflicted with longstanding cardiac conduction disease, she had a pacemaker placed decades ago. It had been subject to many revisions since then but had not been interrogated for a year. Her spinal cord symptoms had progressed with such severity that for the past year that she was wheelchair bound.
Her primary care provider, a clinic nurse practitioner, had seen the patient recently. “The patient is stable and she is cleared for her upcoming surgery,” read her note.
What a relief, I thought to myself.
Then I rolled my eyes.
I shared my frustration with a colleague across the country who practices in a private practice. He recounted a recent case in which a primary care team “cleared” a patient with unstable angina for surgery (it seems the patient’s unstable angina presented so reliably, it was “stable” unstable angina). We together recounted our favorite themes from these pre-operative “clearance” notes. “Avoid hypoxemia and hypercarbia,” read several. “Recommend albuterol if patient develops asthma” read another. “Recommend spinal anesthesia,” read another, referencing an anti-coagulated cardiac cripple. And my personal favorite, “recommend an LMA instead of general anesthesia.”
We both laughed at what Karen Sibert eloquently describes as the ever-present “disconnect between medicine and surgery.”
Why do primary care doctors and cardiologists “clear” our patients for surgery, and what does pre-operative “clearance” really mean? In “clearing” a patient, do they imply a promise of a good outcome?
I think the answer to the first question is a simple one. They “clear” patients because surgeons—and we—ask them to. Somewhere in our professional lives as peri-operative doctors, we hung up our white coats in favor of wearing scrubs full-time. Save the fortunate anesthesiology practices that have a fully integrated pre-operative clinic led by the department of anesthesiology, we defer important workups to other physicians and mid-level providers who, at times, make promises we cannot keep and operate on assumptions about the surgical experience that are not true.
And so we are faced with the common frustration of assessing patients the day of surgery who have received far too many needless tests (chest x-rays and coagulation studies where none are indicated) and some who have received far too few (the absence of an echocardiogram in a patient with a blowing murmur and syncope).
I soldiered on with the spine case. I arrived extra early the next morning, prepared to perform a meticulous history and physical, engage in a family discussion and consult the electrophysiology service. I met the patient in the pre-operative area, where she arrived with a DNR order. My history and physical revealed that she had been aggressively titrated on calcium channel blockers for treatment for hypertension, and despite profound mitral regurgitation, she was fully paced at the rate of 50. We rescinded the DNR after a lengthy family meeting. I requested reprogramming of the pacemaker. I prepared my infusions, invasive monitors and had a heartfelt conversation with the surgeon, who I think partially hoped I’d put the brakes on the 7:30 wheels-up entirely. We planned together how we would approach the day ahead of us.
Fortunately, thanks to the patient’s physical resilience and plenty of good luck, the case proceeded uneventfully.
Unfortunately, it won’t be the last time I read the words, “your patient is cleared for surgery.”
This is a defining time in the profession of anesthesiology. It’s time to capitalize on the changes in our profession and proceed fearlessly on with the establishment of the “surgical home.” If we don’t take ownership of the pre-operative experience, medical and surgical hospitalists, cardiologists, primary care physicians and even mid-level providers will step up and do so. The decision to start or expand an anesthesiology-run pre-operative clinic is not without cost. It may be expensive, burdensome and temporarily take physicians out of more profitable roles. It is complicated to determine who needs to be seen, who needs a phone call, and what tests really need to be ordered and for whom. Sometimes a pre-operative visit will save money and help a patient avoid a cancelled surgery or it may even reveal a life-changing condition. And sometimes the visit will add cost but little value. In our attempts to streamline the experience, unnecessary tests will be ordered and vice versa. But we must work through these challenges, not avoid embracing them entirely.
Let’s end the era of surgical “clearance,” and do what we do best, personally assess the patient’s fitness for anesthesia as soon as the decision has been made by our surgical colleagues to operate. Our primary care and cardiology colleagues are invaluable team members who can best optimize patients well-known to them for their upcoming procedures. They can share their histories, physicals, study results and assessments of the patient’s medical condition. They can share the wisdom and insight about a patient’s condition that come from seeing a patient month after month. But they themselves do not personally deliver anesthetics that have the capacity to induce respiratory and hemodynamic mayhem in the operating room day after day. So they should not promise patients outcomes we cannot guarantee to deliver. Instead of asking them to “clear” our patients, let’s ask for their honest assessment of just how optimally managed a patient’s co-morbidities are. Because we don’t really need or want a “green light” to anesthetize someone; no such “green light” exists. We can leave the long-term medical management to the experts but still take ownership of the pre-operative workup. We are, after all, the architects of the “surgical home.”
Note: Details of the cases described have been changed to protect patient privacy.