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?
Which do you use? Why?
Is one favorable to other in terms of liability?
I provide a risk assessment and recommendations for medical optimization. Only the surgeon and anesthesiologist can "clear" a patient for surgery.
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?
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.
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?
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")