Can Surgeon "medically clear his own patients?"

[aneftp]

Reviewing some charts for upcoming procedures. Got some redneck surgeon at outpatient surgery center I occasionally cover. It's a outpatient lap gallbladder. Usual ASA 3/almost 4 patient. Recently in hospital for CHF 6 weeks ago.

Anyways, see note that surgeon writes on his own patient that patient is medically cleared. I"ve never seen a surgeon "clear" his own patient.

Can't find anything on the American College of Surgeon's website. My surgery friends haven't responded to my texts this morning either.

Obviously we as the anesthesiologist make the final decision to go or not in elective cases. But I just found it highly unusual to see a surgeon write his own medical clearence for his own patient. Just seems like conflict of interest.

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[pgg]

A surgeon clearing a patient is no more absurd than an internist clearing a patient. 🙂

I'm not sure I see a conflict of interest. He's a doctor. There's no guideline or standard that says a surgeon needs anyone's blessing to book a case (except ours, naturally, unless he wants to go sans anesthesia).

Is he "clearing" patients who need optimization or further testing prior to surgery? Ie, are you finding yourself delaying his self-cleared caess, or is he resisting when you tell him the surgery should wait?

 

[sevoflurane]

I agree. I don't care who clears the patient.
If they are not ready the morning of surgery they aren't going to the OR because the patient is "cleared" by a surgeon, internist, cardiologist, etc.
On the other hand, if he does a good job and the patient has been appropriately worked up, then... let's do it.

 

[leaverus]

i don't think there's anything wrong with it either. he's just writing down what every surgeon thinks anyway. it's meaningless to us.

 

[sluggs]

The idea of "clearing" a patient for surgery is flawed. One can do pre-operative risk stratification and pre-operative optimization depending on the patient's condition and the urgency of surgery.

 

[Giic]

I think if there are cardiac issues, then a cardiologist should clear the patient for anesthesia... Not the surgeon... The surgeon can comment about whether or not he feels it is safe to perform the procedure, (given the circumstances, eg prior surgical history, coagulation, etc) but I doubt he's in a position to comment about whether or not anesthesia would be safe for this patient, given the cardia history.
Of course, Anesthesiologist decides finally, but a lot of times Anesthesia looks for a clearance note from cardiologist to make their decision....

 

[Mman]

Of course, Anesthesiologist decides finally, but a lot of times Anesthesia looks for a clearance note from cardiologist to make their decision....

Only the bad ones. All I want from the cardiologist is a statement about whether or not the patient is medically optimized right now. For example, do they feel the patient's on again off again angina deserves a stress test? Are they as good as you want to make them...that's all I want to know.

The phrase "cleared for surgery" is meaningless. And while I'm sure everyone has similar stories, I am reminded of the cardiologist who left us a nice detailed note saying the old guy with severe aortic stenosis was "cleared for spinal but not for general anesthesia". It wasn't worth the effort on my part to clear that one up but we did the case with GA.


It's the essential point of any consult we could ever ask for in terms of anesthesia risk: is the patient as good as they are going to get? If yes, they can have any elective procedure they want as long as they understand the risk. If no, please make them better for an elective procedure and if something is urgent/emergent it's irrelevant.

 

[imfrankie]

Only the bad ones. All I want from the cardiologist is a statement about whether or not the patient is medically optimized right now. For example, do they feel the patient's on again off again angina deserves a stress test? Are they as good as you want to make them...that's all I want to know.

The phrase "cleared for surgery" is meaningless. And while I'm sure everyone has similar stories, I am reminded of the cardiologist who left us a nice detailed note saying the old guy with severe aortic stenosis was "cleared for spinal but not for general anesthesia". It wasn't worth the effort on my part to clear that one up but we did the case with GA.


It's the essential point of any consult we could ever ask for in terms of anesthesia risk: is the patient as good as they are going to get? If yes, they can have any elective procedure they want as long as they understand the risk. If no, please make them better for an elective procedure and if something is urgent/emergent it's irrelevant.

That's the deal. Nobody clears anything unless they are using the Zoll.

 

[Ipassgas]

It seems we are all of one mind. I have never asked for a "clearance" note and likely never will. I do ask for assessment of optimization (usually from cards or pulm, depending). I have also never seen a useful clearance note someone else requested. They usually say cleared for surgery, monitor and maintain stable hemodynamics. Well there goes my plan of not monitoring and chasing nitro boluses with sticks of epi!😉

 

[Idiopathic]

sure, they can clear them for the surgical procedure. you, however, should clear them for the anesthetic, which is usually riskier than the surgery.

 

[jwk]

Reviewing some charts for upcoming procedures. Got some redneck surgeon at outpatient surgery center I occasionally cover. It's a outpatient lap gallbladder. Usual ASA 3/almost 4 patient. Recently in hospital for CHF 6 weeks ago.

Doesn't your practice/facility have policies about which patients are appropriate candidates to be done in an outpatient surgery center?

This patient would fall outside of our policies. Whether anyone, anywhere, "cleared" the patient or not, there would be no question that this patient simply would not be done at one of our outpatient facilities. So - even if we had "cardiac clearance", we still wouldn't do them outside the hospital.

 

[TrustMe]

Unfortunately cancelled a case this morning that the surgeon had told the pt and family that they were still going to have surgery. I hate cancelling cases, but didn't feel like this was the day for this guy.

 

[deleted126335]

American Colege of Surgeons Statement on Principles Underlying Perioperative Responsibility


4. The surgeon is responsible for the proper preoperative preparation of the patient. Minimizing the risk of operation, while providing maximal opportunity for a satisfactory outcome, requires a full appreciation by the surgeon of the patient's condition. Achieving optimal preoperative preparation of the patient will frequently require consultation with other physicians; however, the responsibility for attaining this goal rests with the surgeon.


FWIW.

 

[IlDestriero]

That's the deal. Nobody clears anything unless they are using the Zoll.

I like that. I may have to steal it.
👍

 

[jwk]

American Colege of Surgeons Statement on Principles Underlying Perioperative Responsibility


4. The surgeon is responsible for the proper preoperative preparation of the patient. Minimizing the risk of operation, while providing maximal opportunity for a satisfactory outcome, requires a full appreciation by the surgeon of the patient's condition. Achieving optimal preoperative preparation of the patient will frequently require consultation with other physicians; however, the responsibility for attaining this goal rests with the surgeon.


FWIW.

Considering some of the surgeons I've worked with over the years, that is a REALLY funny statement on several different levels, particularly orthopods.

There's an old adage - "anesthesia exists to keep the patient alive despite the surgeon's best efforts to do otherwise" - that unfortunately has a lot of truth in it with some surgeons.

 

[gasp]

Reviewing some charts for upcoming procedures. Got some redneck surgeon at outpatient surgery center I occasionally cover. It's a outpatient lap gallbladder. Usual ASA 3/almost 4 patient. Recently in hospital for CHF 6 weeks ago.

Anyways, see note that surgeon writes on his own patient that patient is medically cleared. I"ve never seen a surgeon "clear" his own patient.

Can't find anything on the American College of Surgeon's website. My surgery friends haven't responded to my texts this morning either.

Obviously we as the anesthesiologist make the final decision to go or not in elective cases. But I just found it highly unusual to see a surgeon write his own medical clearence for his own patient. Just seems like conflict of interest.

In short, Yes. But we all know medical clearance means nothing so use it with a grain of salt.

 

[aneftp]

Thanks for the responses.

Center has a policy against doing "ASA 4 patients". Of course that's subject to interpretation. A patient with compensated CHF could always be argue as an ASA 3 as long as they haven't had recurring admissions to the hospital for CHF episodes.

Of course medical clearance may not mean anything since we are ultimately responsible for doing the case and the patient's well being. So we have to make the final judgment.

I ended up calling the patient's cardiologist in the afternoon. He said the patient should be fine for GB. He said he saw the patient in the office 4 weeks earlier and the patients blood pressure were elevated (190s/100s). EF was 25% in hospital. Non-ischemic cardiopulmonary. Than he asks why I am calling? I said surgeon was scheduling as an outpatient. Cardiologist said WTF? He assumed the procedure would be done at local hospital "just in case" there were any issues.

Ended up telling the surgeon we can't do the procedure outpatient center. It's one of 6 partners who own the center. I can tell he is annoyed. It's a big dilemnia in physician own centers. Lots of pressure to do cases. They have a lot of incentive to collect facility fees. Like others, hate postponing cases. I don't think I am really cancelling the case, just re-directing to the hospital cause it's not an appropriate case for the surgery center.

 

[OB1🤙]

If an EF less than 30% automatically buys you an ICD from the cardiologists as a prophylactic against sudden malignant arrhythmia, it stands to reason that it buys an ASA 4 designation as a constant threat to life.

 

[BDanes]

I think any EF less than 35% is ASA 4. How is it not?

 

[Dirtball]

My state has a list of certain co-morbidities that preclude us from performing a lap choly at an ASC, who has anything on the list. I don't have it handy, but we can't do ANY PS4's for any procedure. My old frontal lobe has a faint recall the new list even said no PS3's for GB. Check your state regs. I used to do GB's at the ASC for years then the state said none at all, then they came up with a checklist I had to sign.

 

[jennyboo]

I clear my own patients for anesthesia. If I don't clear them, I cancel the case and tell the surgeon what I need done before I'll clear them for anesthesia.

 

[Mman]

My state has a list of certain co-morbidities that preclude us from performing a lap choly at an ASC, who has anything on the list. I don't have it handy, but we can't do ANY PS4's for any procedure. My old frontal lobe has a faint recall the new list even said no PS3's for GB. Check your state regs. I used to do GB's at the ASC for years then the state said none at all, then they came up with a checklist I had to sign.

Our state has no such rules.

 

[Idiopathic]

I think any EF less than 35% is ASA 4. How is it not?

Seems like an arbitrary cutoff

 

[Idiopathic]

My state has a list of certain co-morbidities that preclude us from performing a lap choly at an ASC, who has anything on the list. I don't have it handy, but we can't do ANY PS4's for any procedure. My old frontal lobe has a faint recall the new list even said no PS3's for GB. Check your state regs. I used to do GB's at the ASC for years then the state said none at all, then they came up with a checklist I had to sign.

I dont do any ambulatory cases but do states really regulate this? I just assumed it was clinical judgement and malpractice court that determined what you do at asc's?

 

[45408]

Considering some of the surgeons I've worked with over the years, that is a REALLY funny statement on several different levels, particularly orthopods.

There's an old adage - "anesthesia exists to keep the patient alive despite the surgeon's best efforts to do otherwise" - that unfortunately has a lot of truth in it with some surgeons.

The American College of Surgeons doesn't allow orthopods to become fellows.

 

[urge]

Reviewing some charts for upcoming procedures. Got some redneck surgeon at outpatient surgery center I occasionally cover. It's a outpatient lap gallbladder. Usual ASA 3/almost 4 patient. Recently in hospital for CHF 6 weeks ago.

Anyways, see note that surgeon writes on his own patient that patient is medically cleared. I"ve never seen a surgeon "clear" his own patient.

Can't find anything on the American College of Surgeon's website. My surgery friends haven't responded to my texts this morning either.

Obviously we as the anesthesiologist make the final decision to go or not in elective cases. But I just found it highly unusual to see a surgeon write his own medical clearence for his own patient. Just seems like conflict of interest.

Did he consult himself? IE, he is IM boarded also and wrote a consult to himself? Or was he just writing that the pt was ok to proceed medically in his pre procedure note?

The first one is not adequate. the latter is ok.

Agreed with ASA 4 status. Should be done in the hospital.

 

[HollywdAnesth]

Now that I am in pp, I have often wondered about this. Most of my surgeons get a medical clearance when there is even the slightest whiff of a serious comorbidity. It's not just cardiologists, family practicioners and internists as well.

It makes me wonder why I took so much time in residency to learn the AHA guidelines. I've told many of my urologist colleagues that clearance for an ESWL is largely unnecessary unless the patient has a CRMD. Isn't it up to us to give the final yay or nay? I have seen several discussions on here about preop echos, CXRs, and EKGs. We seem to spend more time talking about who is fit for surgery than any of my colleagues. I know this means extra work, and I know it is certainly not billable. If something were to happen, the doctor who cleared the patient can just point the finger at us for either being bad at our jobs, or not checking his/her work.

That being said. I like having copies of stress tests, and echos on the chart rather than the cover letter stating "clearance" before we begin.

 

[Idiopathic]

Now that I am in pp, I have often wondered about this. Most of my surgeons get a medical clearance when there is even the slightest whiff of a serious comorbidity. It's not just cardiologists, family practicioners and internists as well.

It makes me wonder why I took so much time in residency to learn the AHA guidelines. I've told many of my urologist colleagues that clearance for an ESWL is largely unnecessary unless the patient has a CRMD. Isn't it up to us to give the final yay or nay? I have seen several discussions on here about preop echos, CXRs, and EKGs. We seem to spend more time talking about who is fit for surgery than any of my colleagues. I know this means extra work, and I know it is certainly not billable. If something were to happen, the doctor who cleared the patient can just point the finger at us for either being bad at our jobs, or not checking his/her work.

That being said. I like having copies of stress tests, and echos on the chart rather than the cover letter stating "clearance" before we begin.

i feel like many times the surgeon is trying to head off the anesthesia cancellation/delay for further workup, rather than shotgun clearing every patient as part of a CYA algorithm

 

[Bostonredsox]

Seems like an arbitrary cutoff

Because that is the standardized cutoff for an AICD. Obviously there are pts whse EF recovers above 35 but they had an AICD already placed hastily, but anyone with an EF<35% needs to have an AICD or atleast documentation as to why they do not have one or its our ass. Generally if they do not have one it is because they refused it. Not sure about all ASA scoring levels, but I agree with previous poster, i would imagine an AICD to protect against spontaneous VT/VF would get you a higher ASA. Extrapolate that to all pts with a persistant EF <35% get an AICD, i believe for medicare it is greater than 3 months for them to pay for it, and that means all pts with EF <35% should be an ASA 4. Just my two cents.

As for the original post, 'surgical clearance' does not medically exist. all players are risk-stratified. Low-med-high risk pt for a low-med-high risk procedure. Only a fool rights 'cleared' in their note. asking for medical-legal trouble. The ESRD pt with 2 past MIs needing a lap choley is high risk for a moderate risk procedure. The wording is all standardized in Preop risk stratification guidelines. Furthurmore. You do not need a cardiologist to reisk stratify. Any physician can read and interpret the guidelines. But in general, i get called to admit N/V, abd pain whose GB lights up on U/S, consult surgery for LC, in my H and P I risk stratify them for the surgeon as one of my assesments. Surgeon takes to OR unless i said high risk for hish risk and they get a drain, or unless gas has some other problem with them, usually hypokalemia or some other electrolyte problem the next day that just delays the case a bit until its fixed. I only involve cardio if their pre-operative risk assesments mandates an echo (AS that has not been previously evaluated) or if they need a stress/cath first as their risk is sky high.