"cleared" vs "medically optimized" for surgery?

[jakstat33]

What is the difference in nomenclature between "clearing" and "medically optimizing" for surgery?

Which do you use? Why?

Is one favorable to other in terms of liability?

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[deleted87716]

I provide a risk assessment and recommendations for medical optimization. Only the surgeon and anesthesiologist can "clear" a patient for surgery.

 

[jakstat33]

Can you backup your statement that "only the surgeon and anesthesiologist can clear?"

Patients are "cleared" all the time where I work for surgeries by FP/IM providers. Patients are explicitly sent for "surgery clearance", not risk assessments or med optimization.

I had an attending where I trained who made a point of "medically optimizing" and never writing "cleared," but we did not have much experience with this and I don't know where the terms came from and what the differences are.

I provide a risk assessment and recommendations for medical optimization. Only the surgeon and anesthesiologist can "clear" a patient for surgery.

 

[lowbudget]

Anesthesiologists and surgeons are the ones who determine who goes to the operating room. They are the ones who book the OR, roll the patient back, given the anesthetic, and cut. Not me.

As FM doc, I'm the one who (presumably) has the best information about the patient, which is why my input is important. I take care of all of the patient's problems that I can handle and I'm the center of the multiple doctors my patient sees (at least I hope so, if my patients rely on me). I should have the patient's most up to date medical problem list and medication. I should know the patient's surgical history and any past problems they had in surgery.

My job therefore is to "set" the table, so to speak. I divulge all of the patient's medical problems, medications, etc. in my note and I highlight everything I can think of that potentially could be a problem for this patient for this surgery that I think a reasonable surgeon and anesthesiologist would want to know, so there are no surprises peri-op.

I draw on my surgical and medical rotations, rehab experience in outpatient rotations, and my experience running codes and during procedures to envision the type of things that potentially (for this patient) could be a problem and structure my note that way. I think about the worse case scenario (i.e. patient has bad outcome and needs to go to ICU) and think about what information those doctors would need in that situation.

Therefore, I structure my preoperative clearance note by systems similar to an ICU note, starting with airway, breathing, circulation followed by heme, kidney, liver, and skin/neuro/ortho problems. These are all things that affects a successful intubation, ventilation, hemodynamic stability, hemostasis control or DVT/PE risk, electrolyte abnormalities, clearance of medications/anesthetics, and positioning of the patient during operation.

For example, it's important for an anesthesiologist to know that a patient has degenerative or herniated disk in their neck or obstructive sleep apnea, because that affects intubation. They need to know if the patient's asthma/COPD or allergies are under control, because that may affect ventilation if they have bronchospasms. They need to know if the patient has some nerve or orthopedic problem, because they may need to do the surgery in a different position. They need to know if the patient ever had an adverse effect to anesthetics or ever had problems requiring long term intubation (tracheal stenosis/scarring). Does this patient have a history of MRSA abscesses that I I&D'ed that would suggest he is perhaps a carrier? Does this patient have an addiction problem or medical problem (like a GI/pulmonary problem) that makes the use of narcotics troublesome?

And, if they have an active medical problem that potentially could interfere with anesthesia or surgery, it's my job to discuss with the surgeon whether or not that problem will require attention in the outpatient setting, significant enough that I need to delay surgery (i.e. patient needs catheterization and stent), or if it can be handled prior to the surgery (i.e. patient needs preoperative instead of perioperative beta-blockers for heart protection).

Writing the word "cleared" has no meaning if the team doesn't know on what basis that clearance is based off of. For me, the more information I can provide the team, the better decisions they can make intra/perioperatively. So for me, I consider it a "consultation".

There are surgeons that require that I write the word "clear" or "not cleared" in my note. I write that "no further work up is necessary at this time." But forcing me to write "clear" just shows you the surgeon's ignorance about the role of the anesthesiologist (who serves as the patient's personal physician while the patient is under) and it shows the ignorance of the surgeon as to what my role is as the patient's family doctor.

 

[jakstat33]

Playing devil's advocate, can't a surgeon say his/her job is to determine if surgery is indicated, the actual surgery, and post-op course... not to determine whether patient is stable enough based on comorbidities he is not managing and not in his specialty?

 

[lowbudget]

Playing devil's advocate, can't a surgeon say his/her job is to determine if surgery is indicated, the actual surgery, and post-op course... not to determine whether patient is stable enough based on comorbidities he is not managing and not in his specialty?

Hmm... I don't understand your question. That's exactly what I'm saying. The surgeon is responsible for determining if the surgery is indicated, performing the surgery, and it's post operative course. The surgeon and the anesthesiologist are also responsible in totality for the patient, however, while the patient is under his/her care. Now, a surgeon may outsource/consult the role of diagnosis and management of comorbidities that s/he may feel is outside his/her scope or competency. That is totally appropriate.

Can you clarify your question?

 

[PMPMD]

Anesthesiologists and surgeons are the ones who determine who goes to the operating room. They are the ones who book the OR, roll the patient back, given the anesthetic, and cut. Not me.

As FM doc, I'm the one who (presumably) has the best information about the patient, which is why my input is important. I take care of all of the patient's problems that I can handle and I'm the center of the multiple doctors my patient sees (at least I hope so, if my patients rely on me). I should have the patient's most up to date medical problem list and medication. I should know the patient's surgical history and any past problems they had in surgery.

My job therefore is to "set" the table, so to speak. I divulge all of the patient's medical problems, medications, etc. in my note and I highlight everything I can think of that potentially could be a problem for this patient for this surgery that I think a reasonable surgeon and anesthesiologist would want to know, so there are no surprises peri-op.

I draw on my surgical and medical rotations, rehab experience in outpatient rotations, and my experience running codes and during procedures to envision the type of things that potentially (for this patient) could be a problem and structure my note that way. I think about the worse case scenario (i.e. patient has bad outcome and needs to go to ICU) and think about what information those doctors would need in that situation.

Therefore, I structure my preoperative clearance note by systems similar to an ICU note, starting with airway, breathing, circulation followed by heme, kidney, liver, and skin/neuro/ortho problems. These are all things that affects a successful intubation, ventilation, hemodynamic stability, hemostasis control or DVT/PE risk, electrolyte abnormalities, clearance of medications/anesthetics, and positioning of the patient during operation.

For example, it's important for an anesthesiologist to know that a patient has degenerative or herniated disk in their neck or obstructive sleep apnea, because that affects intubation. They need to know if the patient's asthma/COPD or allergies are under control, because that may affect ventilation if they have bronchospasms. They need to know if the patient has some nerve or orthopedic problem, because they may need to do the surgery in a different position. They need to know if the patient ever had an adverse effect to anesthetics or ever had problems requiring long term intubation (tracheal stenosis/scarring). Does this patient have a history of MRSA abscesses that I I&D'ed that would suggest he is perhaps a carrier? Does this patient have an addiction problem or medical problem (like a GI/pulmonary problem) that makes the use of narcotics troublesome?

And, if they have an active medical problem that potentially could interfere with anesthesia or surgery, it's my job to discuss with the surgeon whether or not that problem will require attention in the outpatient setting, significant enough that I need to delay surgery (i.e. patient needs catheterization and stent), or if it can be handled prior to the surgery (i.e. patient needs preoperative instead of perioperative beta-blockers for heart protection).

Writing the word "cleared" has no meaning if the team doesn't know on what basis that clearance is based off of. For me, the more information I can provide the team, the better decisions they can make intra/perioperatively. So for me, I consider it a "consultation".

There are surgeons that require that I write the word "clear" or "not cleared" in my note. I write that "no further work up is necessary at this time." But forcing me to write "clear" just shows you the surgeon's ignorance about the role of the anesthesiologist (who serves as the patient's personal physician while the patient is under) and it shows the ignorance of the surgeon as to what my role is as the patient's family doctor.

I would love to get one of your pts for the OR. Seriously. We (anesthesiologists) rarely get such detailed and focused pre-op notes.

As you mention, the notes that say "cleared for surgery" aren't worth the paper they're printed on. Also not helpful are the notes from cardiology that say "avoid hypotension, tachycardia, hypoxemia." As if we don't do that with every case. Even worse are the ones that insist on a certain anesthetic technique (neuraxial or regional vs general.) Or insisting on a PA catheter.

As you mention, the 2 best thing you can do for us is to (1) optimize the patient's comorbid conditions and (2) make an concise summary of the said comorbidities. Obviously, optimization will depend on the nature of the surgical procedure. Pt is going for a Whipple for pancreatic CA? Probably not worth taking a few months to get them pristine.

You post is an example of a gold standard for preop notes. Thanks.

 

[jakstat33]

Bluedog responded saying that only a surgeon/anesthesiologist can "clear" a patient for surgery, but actually following our logic they aren't responsible for clearing the patient at all. It's actually PCP's job to clear and surgeon/anesthesiologist to manage the surgery.

In general, I am trying to figure out the difference between saying someone is "medically optimized" vs "cleared" (if there is any, it doesn't sound like it though some physicans make a point of writing medically optimize and never using "cleared")

Hmm... I don't understand your question. That's exactly what I'm saying. The surgeon is responsible for determining if the surgery is indicated, performing the surgery, and it's post operative course. The surgeon and the anesthesiologist are also responsible in totality for the patient, however, while the patient is under his/her care. Now, a surgeon may outsource/consult the role of diagnosis and management of comorbidities that s/he may feel is outside his/her scope or competency. That is totally appropriate.

Can you clarify your question?

 

[PMPMD]

Bluedog responded saying that only a surgeon/anesthesiologist can "clear" a patient for surgery, but actually following our logic they aren't responsible for clearing the patient at all. It's actually PCP's job to clear and surgeon/anesthesiologist to manage the surgery.

In general, I am trying to figure out the difference between saying someone is "medically optimized" vs "cleared" (if there is any, it doesn't sound like it though some physicans make a point of writing medically optimize and never using "cleared")

The PCP can state a pt is "cleared," but the anesthesiologist is the gatekeeper to the OR. If we feel it would be unsafe to take a pt back, they don't go. I don't use the word "cleared" in my practice. Either they go now, or they come back later.

 

[FutureInternist]

To a lot of patients, cleared may imply "There is no way you're going to have a bad outcome". That is why all my notes (although the attending signs them) say "Medically optimised". Then we try to explain to the patient that they are as best as they are going to get and now it's between them & their surgeon

 

[ssmallz]

Medically cleared - only an anesthesiologist can clear a pt for the OR, this is a misnomer when surgeons ask other specialist to "clear pts" b/c what they really want is for that specialty to optimize the pt

Medically optimized - pt is still sick but is as good a he/she is gonna get. Pt has a hx of asthma? Pt gets asthma attacks 2x/week on only albuterol = not optimized, Pt has asthma attacks once/month on steroids and albuterol, seen pulm in past = optimized. The pt still has asthma but they are as good as they can get. Pt has a hx of DOE or chest pain? Has the proper testing been done to make sure that this is non cardiac? Has the proper medical management been implemented so that this pt is as good as he will get prior to surgery?

"As good as they can be" That's the key phrase right there. We all understand that these pts are sick and will continue to be sick for the rest of their lives. Whenever you think about evaluating a pt for surgery, ask yourself this simple question "Can the pt be made better in a reasonable amount of time?" If the answer is yes.......then the pt isn't optimized and interventions should be done prior to surgery, if the answer is no then the pt is good to go.


Lowbuget - your post is absolutely spot on and should be forwarded to every FP/IM doc out there on how to properly work up a pt who is about to undergo surgery.

 

[HelloGoodbye]

Hi guys, sorry to rehash this old thread, but just curious what you guys do. My typical "Clearance statement" is:

"The patient is scheduled for an intermediate risk orthopedic procedure and he can complete 4 METS of physical activity (which is associated with lower intraoperative cardiac risk). Based on the revised cardiac risk index his risk of intraoperative mortality is 0.4%. No further testing is recommended prior to the procedure."

However, if the patient is at a higher risk for surgery (i.e. prior stenting/MI, etc). Do you ever add to the note something like "Pt is at Higher risk due to XYZ. Surgeon and patient should decide whether to proceed"?

I never know how to word it if they are at a higher risk, but no further testing is recommended.

 

[deleted87716]

I'll say they're at low/average/high risk. I use the term "medically optimized," not "cleared." Whether or not any further testing is needed depends on the situation. If pre-op cardiac or pulmonary risk is a serious concern, I'll order a stress test and/or PFTs, or delay the surgery until they're evaluated and "cleared" by cardiology/pulmonology.

 

[septoplasty]

I agree with BlueDog, was tought thoroughly in residency to always document "clearance" as "low/med/high risk", and identify areas of concern. The Anesthesio/Surgeon can decide if they want to proceed with the surgery there after.

I think alot of the surgery "clearance"/risk stratification "algorithms" follow the same path.

 

[Bacchus]

Our preoperative evaluation template is mandated to be used. It calculates risk and does NOT use the word clear anywhere. I document in the discussion what the patient and I discussed and if I recommend proceeding with caution or against. Ultimately, if the surgeon if god ng to operate they are going to operate. That said, I have strongly advocated a few times the patient research other options.