Internist won't "clear" patient

[Planktonmd]

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It's a strange situation I encountered today:
Morbidly obese woman (400 pounds) with HX of Asthma and HTN.
No cardiac history and had a negative stress test 1 year ago.
Wants to have gastric bypass surgery.
Internist tells her that he will not write the note that the surgeon requires stating that she is medically optimized for the surgery, he won't even refer her to someone else who would! because it is too much liability 😀
He wouldn't even tell her what she is supposed to do so he would feel comfortable with her having the surgery.
The surgeon would not proceed with surgery without such note.
The patient is here for her pre-op interview and asking for my advice.
What would you say??
The internist is not a new guy by the way (20+ years practice), but not one of our regulars.

 

[filter07]

As a surgery resident I think it is ludicrous to send a patient to an internist for "clearance" for surgery. A true surgeon should be able to stratify the risks of a routine patient like this. Of course the internist would not clear this woman. What does an internist know about the risks of surgery? Why would we expect an internist to know any of this? It's obvious that this responsibility belongs with the surgeon! The surgeon is the one that see morbidly obese patients all the time for gastric bypass surgery. The surgeon is the one that tracks complications in this type of patient. The surgeon is the one that sees the patient through his or her post-operative course. Why on earth is the surgeon passing off this vital responsibility to someone whose involvement in surgery is so far removed? This makes no sense to me, and I find it quite irritating.

On the other hand, if the patient had complicated risk factors such as valvular disease, severe pulmonary issues, then having the input of specialists is appropriate.

 

[Pilot Doc]

What would you say??
QUOTE]

Find another internist.

 

[Lonestar]

I would give her my two cents about the risks of proceeding with surgery. Ultimately she has to make the decision. As long as her HTN and Asthma are well controlled, I do not see a reason to delay surgery.

This is a no brainer. If the pt wants surgery, and she is aware of the risks of surgery and her medical conditions are well controlled , then she is good to go.

 

[Jeff05]

the issues pertinent to the perioperative critical care of this patient are handled by anesthesiology and not surgery.

major issues:
1. airway management: anesthesia
2. intraoperative ventilation issues: anesthesia
3. intraoperative hemodynamics: anesthesia
4. extubation: anesthesia
5. no-extubation: postop ventilation in pacu/sicu: anesthesia

the surgeon can risk stratify all he/she wants. the ultimate call to proceed and responsibility for the periop management falls to the anesthesiologist.

 

[ProRealDoc]

the issues pertinent to the perioperative critical care of this patient are handled by anesthesiology and not surgery.

major issues:
1. airway management: anesthesia
2. intraoperative ventilation issues: anesthesia
3. intraoperative hemodynamics: anesthesia
4. extubation: anesthesia
5. no-extubation: postop ventilation in pacu/sicu: anesthesia

the surgeon can risk stratify all he/she wants. the ultimate call to proceed and responsibility for the periop management falls to the anesthesiologist.

ridiculous. Someone said once that internists optimize and anesthesiologists clear patients for surgery. I say explain the risks to the patient and proceed. These calls should be made by anesthesia not medicine. Medicine docs can go and uhhh... keep rounding.

 

[Bertelman]

Call the surgeon, tell him he doesn't need a damn medicine doc to tell him when to proceed with surgery. Complete your pre-op, give her instructions, and look forward to surgery.

When did medicine consultation become a requirement for surgery? This can't be the sickest obese woman to get gastric bypass. They all have HTN.

 

[ProRealDoc]

It's a strange situation I encountered today:
Morbidly obese woman (400 pounds) with HX of Asthma and HTN.
No cardiac history and had a negative stress test 1 year ago.
Wants to have gastric bypass surgery.
Internist tells her that he will not write the note that the surgeon requires stating that she is medically optimized for the surgery, he won't even refer her to someone else who would! because it is too much liability 😀
He wouldn't even tell her what she is supposed to do so he would feel comfortable with her having the surgery.
The surgeon would not proceed with surgery without such note.
The patient is here for her pre-op interview and asking for my advice.
What would you say??
The internist is not a new guy by the way (20+ years practice), but not one of our regulars.

Step up to the mike with micatin (like JPP says) and proceed.

 

[Planktonmd]

I love all the emotional stuff about who is responsible for what and who runs the show and all that great residency stuff.
Unfortunately this is not residency this is private practice.
The patient is the surgeon's patient, he brought her to us and if he wants an internist to see her before he operates on her it's his decision.
Internists "clearing" patients for surgery are very common in the real world and on top of that, if the internist does not say the patient is good to have bariatric surgery, there is a good chance that her insurance carrier will not pay for it.
So, assuming that the surgeon might listen to you and proceed with the surgery if you tell him to do so, and assuming that the insurance company will not insist on the input from the primary doctor, are you willing to override the internist's opinion (even if you think it's BS) and proceed with surgery??
Is it your job as a consultant who saw the pt. today for the first time to make this decision?
Is it ethically OK for you to tell her that her Doctor is an idiot (in a nice way) and that she shoud see another internist?

 

[Jeff05]

is it our job to make the decision if a patient is ok for surgery? of course it is. that's a part of our job description.

there is NO SUCH thing as "clearance." there is ONLY risk stratification. since internists know absolutely nothing about anesthesiology their only job is to look at that paper that stratifies patients and procedures. this guy probably still prescribes digoxin for all of his patients...

i would diplomatically tell her that the internist is not actually saying that she "can't have the surgery." he is simply voicing his concern that the risks associated with surgery are higher than for a completely healthy individual.

I love all the emotional stuff about who is responsible for what and who runs the show and all that great residency stuff.
Unfortunately this is not residency this is private practice.
The patient is the surgeon's patient, he brought her to us and if he wants an internist to see her before he operates on her it's his decision.
Internists "clearing" patients for surgery are very common in the real world and on top of that, if the internist does not say the patient is good to have bariatric surgery, there is a good chance that her insurance carrier will not pay for it.
So, assuming that the surgeon might listen to you and proceed with the surgery if you tell him to do so, and assuming that the insurance company will not insist on the input from the primary doctor, are you willing to override the internist's opinion (even if you think it's BS) and proceed with surgery??
Is it your job as a consultant who saw the pt. today for the first time to make this decision?
Is it ethically OK for you to tell her that her Doctor is an idiot (in a nice way) and that she shoud see another internist?

 

[bostonblaz]

Really hard to step on toes. We all know this women is probably one of the best 400 lbs we see, no DM2, no cad. The hardest part of this whole thing will be putting in her epidural and taping it so it wont come out. we are not the ones who have to do anything with this women once she rolls out of pacu. For all preops I do weather in the PAT clinic or on the wards I make it a point to tell the person anything they need to know or ask that involves the anesthesia portion of her surgical experience. I wil never make a comment about the surgeon or her internal medicine doc because that is not why I am seeing them. Then I call the surgeon and tell him what I belive to be best for the patient and then leave it up to them to decide because up until i place their iv i am only the consultant physcian involved in their perioperative care. Once that threshold is crossed and I am then their perioperative physcian I can tell them excatly how I feel.

 

[Bertelman]

...The patient is the surgeon's patient, he brought her to us and if he wants an internist to see her before he operates on her it's his decision....

Maybe I'm not understanding how she arrived in your clinic if she's not been "cleared" for surgery.

Pointless visit if the surgeon won't cut without the internist's approval.

 

[thegasman]

Really hard to step on toes. We all know this women is probably one of the best 400 lbs we see, no DM2, no cad. The hardest part of this whole thing will be putting in her epidural and taping it so it wont come out. we are not the ones who have to do anything with this women once she rolls out of pacu. For all preops I do weather in the PAT clinic or on the wards I make it a point to tell the person anything they need to know or ask that involves the anesthesia portion of her surgical experience. I wil never make a comment about the surgeon or her internal medicine doc because that is not why I am seeing them. Then I call the surgeon and tell him what I belive to be best for the patient and then leave it up to them to decide because up until i place their iv i am only the consultant physcian involved in their perioperative care. Once that threshold is crossed and I am then their perioperative physcian I can tell them excatly how I feel.

Epidural????? prop sux tube dude - c'mon.

 

[Planktonmd]

is it our job to make the decision if a patient is ok for surgery? of course it is. that's a part of our job description.

there is NO SUCH thing as "clearance." there is ONLY risk stratification. since internists know absolutely nothing about anesthesiology their only job is to look at that paper that stratifies patients and procedures. this guy probably still prescribes digoxin for all of his patients...

i would diplomatically tell her that the internist is not actually saying that she "can't have the surgery." he is simply voicing his concern that the risks associated with surgery are higher than for a completely healthy individual.

I did not ask if it's our job to decide if someone is OK for surgery, that's not the point of this whole discussion.
I asked if you think it is your job to override the primary physician's opinion although so far you are only a cosultant who just met the patient for the first time.
I agree with you otherwise, the word clearance is silly and internists should have no business dictating who goes to to the OR and who doesn't, but guess what, they do everyday and more frequently than you think.
You will soon find out that I am telling you the truth.
🙂

 

[Planktonmd]

Maybe I'm not understanding how she arrived in your clinic if she's not been "cleared" for surgery.

Pointless visit if the surgeon won't cut without the internist's approval.

She came to see me because when they schedule these patients for their preop workup they also schedule them to come and see one of us.
But usually they come to see us at the end of their process and all the issues are usually resolved at that point, this one was different though.

 

[Pilot Doc]

So, assuming that the surgeon might listen to you and proceed with the surgery if you tell him to do so, and assuming that the insurance company will not insist on the input from the primary doctor, are you willing to override the internist's opinion (even if you think it's BS) and proceed with surgery??
Is it your job as a consultant who saw the pt. today for the first time to make this decision?
Is it ethically OK for you to tell her that her Doctor is an idiot (in a nice way) and that she shoud see another internist?

We are consultants. We don't override anyone. We are asked a question and give an opinion. In this case, you tell the surgeon that you have no objections to anesthetizing her. Whether he brings the patient to the OR is between him and the patient. The internists opinion is relevant only to the extent the surgeon cares about it.

There's no need to tell her, nicely or otherwise, that her doctor is an idiot. Simply suggest a 2nd opinion.

 

[Noyac]

Well after laughing my arse off at this internist I would do what many of you said. Proceed with surgery. She's only 400 lbs. This is a slam dunk.

 

[2win]

👍

We are consultants. We don't override anyone. We are asked a question and give an opinion. In this case, you tell the surgeon that you have no objections to anesthetizing her. Whether he brings the patient to the OR is between him and the patient. The internists opinion is relevant only to the extent the surgeon cares about it.

There's no need to tell her, nicely or otherwise, that her doctor is an idiot. Simply suggest a 2nd opinion.

Perfect answer!

 

[CrazyJake]

I can honestly say, I've never seen an internist clear anyone for surgery...usually a specialist if there is a organ system in question or Anesthesia evaluates.

The internist where I'm rotating right now would never 'clear' anyone and doubt they'd want any part of that action.

 

[Planktonmd]

We are consultants. We don't override anyone. We are asked a question and give an opinion. In this case, you tell the surgeon that you have no objections to anesthetizing her. Whether he brings the patient to the OR is between him and the patient. The internists opinion is relevant only to the extent the surgeon cares about it.

There's no need to tell her, nicely or otherwise, that her doctor is an idiot. Simply suggest a 2nd opinion.

Correct,
You are a consultant and at this point you are one of 2 consultants that have been asked for input on this patient.
I think the best thing you can do is to document your opinion and inform the surgeon of it but that's where your job ends.
I wrote that I don't see a contraindication for proceeding with the suggested surgery and told the nurses to fax my consult to the surgeon's office.
I did not criticize the internist (although I really wanted to).
The main reason for posting this case is to bring up the issue of internists and other specialists "clearing" patients for surgery, it's a deeply rooted culture that is more common than our resident colleagues might know and you will almost certainly be faced with it if you choose the private practice route.

 

[filter07]

Having worked at a private practice PCP office in the past, I can verify that many patients are sent to PCPs for "cardiac clearance." This usually entails some sort of stress test and whatnot, which is fine. However if this particular patient had this work up in the past, sending the patient to the internist again for "clearance" is a waste of everyone's time, academic or private practice included. Although in private practice maybe some PCPs are hard up for clients and appreciate referrals like this.

 

[Gern Blansten]

What the internist should have said is "This patient is cleared for surgery but only for a spinal block." "Oh, and by the way, avoid hypotension and hypoxia."

 

[geauxg8rs]

I agree with the internist. She should only have the gastric bypass when she has dieted enough to get down to her ideal body weight. then and only then will she be optimized for the bypass.

 

[Bertelman]

I agree with the internist. She should only have the gastric bypass when she has dieted enough to get down to her ideal body weight. then and only then will she be optimized for the bypass.

Ohhhh....I get it. You're not cleared for surgery unless you lose all the weight you were hoping to lose with the bypass.

If she's IBW, why does she need surgery? While we're at it, would you ask ALL patients to achieve ideal body weight prior to elective surgery?

 

[phassett74]

This is a very interesting thread, particularly considering the forum heading it is under.

Here are some observations:

I have frequently seen anesthesia "block" surgical patients due to non-optimal creatinine, potassium, etc. Do you still have the same viewpoint if this woman had CKD and a creatinine of 1.8? We all know it isn't going to get any better, but chances are she still might not pass your pre-screen and get "clearance".

Much easier to point fingers when it is not your license being called into question when things go wrong. Perhaps that internist knows the patient very well, and there are things that he can't chart that might reveal the entire truth behind him not clearing her - you should recognize this.

Surgeons routinely hedge their patients to internists, the same as ED docs. Bascially it is a cover your ass thing. Do you think internists like "risk stratifying" or "clearing" everyone with DM and a history of CAD? I have always wondered why surgeons, or anesthesia for that matter (who claim to be the "medicine" of the OR) can't read the same published guidelines and get to it. Again, we all know the reason - you don't want your name to be the sole foci of the attorney if things go south.

As I said, I found reading this forum fairly strange in its general attitude toward internists. You all have rotated with them, and know that they are spread too thin, and generally leaned on too hard. I am not sure why people who are comfortable putting people to sleep, and basically being responsible for their primary, life-sustaining functions, are unable to remove this pain in the ass responsibility from internists, since you alledge to "know better" anyway.

By the way, based on what I have seen, surgeons certainly do not know better regarding the basic medical needs of their patients. There are exceptions, but largely they cut, and seem to be happy just knowing their domain, and not dealing with basic things like fluids, lytes, acid base - that is why everyone coming off a big surgery on "house cocktail of D5W +" gets SIADH and people consult internists and nephrologists to solve the "mystery".

Come on guys!

 

[Dimoak]

How old is the patient?

 

[Noyac]

This is a very interesting thread, particularly considering the forum heading it is under.

Here are some observations:

I have frequently seen anesthesia "block" surgical patients due to non-optimal creatinine, potassium, etc. Do you still have the same viewpoint if this woman had CKD and a creatinine of 1.8? We all know it isn't going to get any better, but chances are she still might not pass your pre-screen and get "clearance".

Much easier to point fingers when it is not your license being called into question when things go wrong. Perhaps that internist knows the patient very well, and there are things that he can't chart that might reveal the entire truth behind him not clearing her - you should recognize this.

Surgeons routinely hedge their patients to internists, the same as ED docs. Bascially it is a cover your ass thing. Do you think internists like "risk stratifying" or "clearing" everyone with DM and a history of CAD? I have always wondered why surgeons, or anesthesia for that matter (who claim to be the "medicine" of the OR) can't read the same published guidelines and get to it. Again, we all know the reason - you don't want your name to be the sole foci of the attorney if things go south.

As I said, I found reading this forum fairly strange in its general attitude toward internists. You all have rotated with them, and know that they are spread too thin, and generally leaned on too hard. I am not sure why people who are comfortable putting people to sleep, and basically being responsible for their primary, life-sustaining functions, are unable to remove this pain in the ass responsibility from internists, since you alledge to "know better" anyway.

By the way, based on what I have seen, surgeons certainly do not know better regarding the basic medical needs of their patients. There are exceptions, but largely they cut, and seem to be happy just knowing their domain, and not dealing with basic things like fluids, lytes, acid base - that is why everyone coming off a big surgery on "house cocktail of D5W +" gets SIADH and people consult internists and nephrologists to solve the "mystery".

Come on guys!

You are a med stud, right? Thanks for your input and I understand where you are coming from. But you have a few things wrong here, if I may. We clear pts for surgery all the time and usually with much bigger (no pun intended) medical problems. It is my understanding that the internist doesn't agree with the need for gastric bypass in this case and I may not disagree with that internist. The problem is, most anesthesia groups don't have the luxury of time on our hands to see every pt 2 weeks b/4 surgery. The Internist gets compensated for these visits and are usually happy to do them since it is their pt in the first place. If we say they are not "optimized" for surgery then they must go back to the internist for the necessary optimization. So why add the additional step, cost and time.

It's not about liability. I have never heard of an internist being sued b/c they cleared someone for surgery and the pt did poorly. Maybe it has happened but not frequently enough to be worried. There should never be "things he can't chart" if they pertain to the pts safety that other physicians must know. Thats unacceptable.

We are not hard on internist until they give us a reason. That usually is writing in the chart stupid comments which they have no business writing like, "cleared for spinal only, avoid hypotension/hypoxia, needs close monitoring of vitals 😱, may have large breakfast due to DM, etc." You get the point?

Thanks for your input, thats what some of us are here for.

 

[Southpaw]

This is a very interesting thread, particularly considering the forum heading it is under.

Here are some observations:

I have frequently seen anesthesia "block" surgical patients due to non-optimal creatinine, potassium, etc. Do you still have the same viewpoint if this woman had CKD and a creatinine of 1.8? We all know it isn't going to get any better, but chances are she still might not pass your pre-screen and get "clearance".

Much easier to point fingers when it is not your license being called into question when things go wrong. Perhaps that internist knows the patient very well, and there are things that he can't chart that might reveal the entire truth behind him not clearing her - you should recognize this.

Surgeons routinely hedge their patients to internists, the same as ED docs. Bascially it is a cover your ass thing. Do you think internists like "risk stratifying" or "clearing" everyone with DM and a history of CAD? I have always wondered why surgeons, or anesthesia for that matter (who claim to be the "medicine" of the OR) can't read the same published guidelines and get to it. Again, we all know the reason - you don't want your name to be the sole foci of the attorney if things go south.

As I said, I found reading this forum fairly strange in its general attitude toward internists. You all have rotated with them, and know that they are spread too thin, and generally leaned on too hard. I am not sure why people who are comfortable putting people to sleep, and basically being responsible for their primary, life-sustaining functions, are unable to remove this pain in the ass responsibility from internists, since you alledge to "know better" anyway.

By the way, based on what I have seen, surgeons certainly do not know better regarding the basic medical needs of their patients. There are exceptions, but largely they cut, and seem to be happy just knowing their domain, and not dealing with basic things like fluids, lytes, acid base - that is why everyone coming off a big surgery on "house cocktail of D5W +" gets SIADH and people consult internists and nephrologists to solve the "mystery".

Come on guys!

This isn't going to go over well here.....that's for sure.

But I can guaran-damn-tee you that Plank wishes the internist hadn't been consulted, or the consult note was shredded, and the surgeon just had the patient come in for pre-op so they could get on with the surgery.

 

[Planktonmd]

This is a very interesting thread, particularly considering the forum heading it is under.

Here are some observations:

I have frequently seen anesthesia "block" surgical patients due to non-optimal creatinine, potassium, etc. Do you still have the same viewpoint if this woman had CKD and a creatinine of 1.8? We all know it isn't going to get any better, but chances are she still might not pass your pre-screen and get "clearance".

Much easier to point fingers when it is not your license being called into question when things go wrong. Perhaps that internist knows the patient very well, and there are things that he can't chart that might reveal the entire truth behind him not clearing her - you should recognize this.

Surgeons routinely hedge their patients to internists, the same as ED docs. Bascially it is a cover your ass thing. Do you think internists like "risk stratifying" or "clearing" everyone with DM and a history of CAD? I have always wondered why surgeons, or anesthesia for that matter (who claim to be the "medicine" of the OR) can't read the same published guidelines and get to it. Again, we all know the reason - you don't want your name to be the sole foci of the attorney if things go south.

As I said, I found reading this forum fairly strange in its general attitude toward internists. You all have rotated with them, and know that they are spread too thin, and generally leaned on too hard. I am not sure why people who are comfortable putting people to sleep, and basically being responsible for their primary, life-sustaining functions, are unable to remove this pain in the ass responsibility from internists, since you alledge to "know better" anyway.

By the way, based on what I have seen, surgeons certainly do not know better regarding the basic medical needs of their patients. There are exceptions, but largely they cut, and seem to be happy just knowing their domain, and not dealing with basic things like fluids, lytes, acid base - that is why everyone coming off a big surgery on "house cocktail of D5W +" gets SIADH and people consult internists and nephrologists to solve the "mystery".

Come on guys!

This thread was not intended to insult internists or to undermine their role.
This was a simple real life example of a primary care physician who is practicing peri-operative medicine, although he does not seem to want or have the ability to practice this field of medicine.
Not entirely his fault, it is the fault of the system that placed him in the center of a process he has little understanding or training to handle.
I also think that your understanding about what anesthesiologists do is at best partial and it might be a good idea if you do a rotation in an anesthesia department and watch the residents and attendings work, there is a chance you might see things differently after that.

 

[Planktonmd]

how old is the patient?

40 y/o

 

[CambieMD]

$

 

[NavyFlightDoc]

I'm gonna have to disagree with the post above about surgeons not understanding electrolytes, etc. At least, my experience with residents/attending physicians in a mixed SICU/MICU setting as an intern would suggest the opposite is true. Of course, it might just be "thoroughness" and academic rigor, that makes the medicine resident call his senior, then his chief and then check with an attending before making a decision on whether to treat his patient's K of 3.5, or Phos of 2.7, etc.

I think it's more a sign of the institutionalized fear of making a decision that characterizes some groups in medicine. ("clinical correlation required," anyone?)

As for SIADH in ALL the surgical patients, that's just silly.

 

[urge]

She is obviously too fat for surgery.

No surgery for her.

 

[Scrub MD]

I have always wondered how this worked everywhere else. On my FP rotation, we would often get patients to be "cleared" for surgery. The FP would look at the guideline checklist and order the appropriate tests. It makes more sense to leave out the FPs and internists as the surgeon knows the most about the surgery and post-op complications while the Anesthesiologist knows the most about pre-op, intra-op and PACU care.

 

[fakin' the funk]

I have always wondered how this worked everywhere else. On my FP rotation, we would often get patients to be "cleared" for surgery. The FP would look at the guideline checklist and order the appropriate tests. It makes more sense to leave out the FPs and internists as the surgeon knows the most about the surgery and post-op complications while the MDA knows the most about pre-op, intra-op and PACU care.

What's an MDA?

(while we're at it)

What's an FP?

 

[Bertelman]

What's an MDA?

(while we're at it)

What's an FP?

MD Anesthesiologist.

Family Practitioner.

 

[howelljolly]

Would somebody explain this to me like Im a three year old? It seems like we are going in circles with this, and I still dont get it.

If obtaining clearance from internal med is not simply to distribute the lability, why do it? The medicine guys are just going to go through a checklist and risk stratify the patient. Surgery or Anesthesia can certainly do that themselves. What do internists know about intraoperative physiology?

Of course, theres a need for specialist evaluation for card and pulm problems... but apart from that, why involve IM at all?

 

[RabbMD]

Would somebody explain this to me like Im a three year old? It seems like we are going in circles with this, and I still dont get it.

If obtaining clearance from internal med is not simply to distribute the lability, why do it? The medicine guys are just going to go through a checklist and risk stratify the patient. Surgery or Anesthesia can certainly do that themselves. What do internists know about intraoperative physiology?

Of course, theres a need for specialist evaluation for card and pulm problems... but apart from that, why involve IM at all?

Very good question. The answer is anesthesiologists (at least recent grads) generally don't. It is the busy surgeon usually who barely sees his patient and wants a PCP to write an H/P for him.

Most of the problems I see in pre-oping patients comes from having too little time (the day before a major surgery I see a chart where nurses take histories and allude to major medical problems without information) and not enough information. A google-like online health record system would solve a big part of my problems. Being able to see cath reports, stress tests that are reported by the patient as "normal" would help a ton.

Sometimes you send a patient back to their pcp because you sense an underlying medical issue unrelated to the surgery. An example would be say hyponatremia in the mid 120s for a knee scope patient who has a ER visit for dizziness and confusion 2 weeks ago and 2 months ago had a normal NA per hospital records. Prior to an elective case I want to make sure we don't have a lung cancer causing SIADH or something. I would then ask for "clearance" here, but what I really want and try to personally talk to the PCP is "I think this needs to be worked up regardless of the surgery."

We don't want clearance really, we just want information (which unfortunately patients generally are not well informed about their own care, and even if they were because of the thread of malpractice you can not necessarily trust "taking a patients word for it") and if the case is elective you might as well control the patients, BP, glucose, and lytes as well as can be done.

 

[jwk]

Epidural????? prop sux tube dude - c'mon.

We used to do epidurals for POSTOP pain management all the time with open gastric bypasses. We rarely see those anymore, and we don't do them for laparoscopies.

 

[fakin' the funk]

MD Anesthesiologist.

Family Practitioner.

I'm not familiar with either of those terms. They appear to be nonstandard.

 

[jwk]

Much easier to point fingers when it is not your license being called into question when things go wrong. Perhaps that internist knows the patient very well, and there are things that he can't chart that might reveal the entire truth behind him not clearing her - you should recognize this.
!

You must be a former nurse - usually it's only nurses who bring up the "my license is on the line" BS.

 

[Southpaw]

You must be a former nurse - usually it's only nurses who bring up the "my license is on the line" BS.

This must be taught universally in Nursing 101. I've heard it countless times from nursing friends of mine.

 

[jwk]

I love all the emotional stuff about who is responsible for what and who runs the show and all that great residency stuff.
Unfortunately this is not residency this is private practice.
The patient is the surgeon's patient, he brought her to us and if he wants an internist to see her before he operates on her it's his decision.
Internists "clearing" patients for surgery are very common in the real world and on top of that, if the internist does not say the patient is good to have bariatric surgery, there is a good chance that her insurance carrier will not pay for it.
So, assuming that the surgeon might listen to you and proceed with the surgery if you tell him to do so, and assuming that the insurance company will not insist on the input from the primary doctor, are you willing to override the internist's opinion (even if you think it's BS) and proceed with surgery??
Is it your job as a consultant who saw the pt. today for the first time to make this decision?
Is it ethically OK for you to tell her that her Doctor is an idiot (in a nice way) and that she shoud see another internist?

Although everyones uses the common term "clearing" for surgery, it really is pretty much a misnomer. The internist does not make the decision (or they certainly don't at our place). And I've never heard that their approval is required for ANY surgical procedure, bariatric or otherwise, or that the insurance company wouldn't pay, unless perhaps this is an HMO requirement.

It certainly makes good sense for the patient to see their internist (or cardiologist or pulmonologist) before major surgery. They may give a much more complete picture of the patients medical issues than the surgeon will (most of our surgeon-written H&Ps are near worthless, even from the better surgeons). That's all we want - we don't want a "clearance". We want a good overall picture of that patients issue(s) and hopefully to know that they are well optimized for surgery. That's it. However, most of these medical specialists don't know squat about anesthesia. We still get cardiologists clearing patients for "spinal anesthesia only" that are still on plavix and aspirin, and internists with consults that say "maintain oxygenation and avoid hypotension".

Plank, as far as your particular internist/surgeon - if the surgeon says he won't proceed without this particular internists OK, fine. Don't do that patient. That's their problem, not yours. You're not really part of the decision-making process at that point. You're off the hook. The surgeon will probably realize sooner or later that this may not be the internist he would like his patients to see preoperatively if he wants to actually operate.

 

[core0]

Very good question. The answer is anesthesiologists (at least recent grads) generally don't. It is the busy surgeon usually who barely sees his patient and wants a PCP to write an H/P for him.

Most of the problems I see in pre-oping patients comes from having too little time (the day before a major surgery I see a chart where nurses take histories and allude to major medical problems without information) and not enough information. A google-like online health record system would solve a big part of my problems. Being able to see cath reports, stress tests that are reported by the patient as "normal" would help a ton.

Sometimes you send a patient back to their pcp because you sense an underlying medical issue unrelated to the surgery. An example would be say hyponatremia in the mid 120s for a knee scope patient who has a ER visit for dizziness and confusion 2 weeks ago and 2 months ago had a normal NA per hospital records. Prior to an elective case I want to make sure we don't have a lung cancer causing SIADH or something. I would then ask for "clearance" here, but what I really want and try to personally talk to the PCP is "I think this needs to be worked up regardless of the surgery."

We don't want clearance really, we just want information (which unfortunately patients generally are not well informed about their own care, and even if they were because of the thread of malpractice you can not necessarily trust "taking a patients word for it") and if the case is elective you might as well control the patients, BP, glucose, and lytes as well as can be done.

Some FP and IM want to do the H/Ps since they reimburse relatively well and are pretty easy to do. On the other hand referring someone to IM who doesn't want to "clear" the patient is not particularly helpful.

In transplant we get requests to clear patients from time to time. Just as stated here, we don't "clear" people, we tell the referring surgeon whether the patient is optimized from a transplant standpoint and our assessment of the risk. On the other hand we see patients where we wish we had been consulted. Like the gentleman who had exposed bone after an ENT procedure. If someone had asked we would have taken the patient off Sirolimus and onto an IS regime that would actually allow wound healing.

JWK - in the early days of Bariatric surgery you could get around the general prohibition from insurance companies by documenting "abdominal compartment syndrome". At the time this had to come from an internist not the surgeon. These days with the general approval I can't see this being a requirement.

David Carpenter, PA-C

 

[Bertelman]

I'm not familiar with either of those terms. They appear to be nonstandard.

MDA certainly is. It's generally loathed on this board, and is a bit of a nod to CRNAs.

I'm not sure how you haven't heard of FP, though. Do you not have any colleagues entering a Family Practice residency? I just used the Family Practitioner title to conform the usage to the abbreviation, but I'm not sure that is used so much in the U.S. Either way, I'm surprised you have never heard of FP, whether Family Practice or Practitioner.

 

[Planktonmd]

JWK - in the early days of Bariatric surgery you could get around the general prohibition from insurance companies by documenting "abdominal compartment syndrome". At the time this had to come from an internist not the surgeon. These days with the general approval I can't see this being a requirement.

David Carpenter, PA-C

Many insurance policies (almost all BCBS contracts) exclude bariatric surgery under any circumstances, some of them will allow it only if medically necessary and that medical necessity is usually established by the primary physician who is also required to provide additional information like the patient's weight over the past 6 years and the patient's attempts at weight loss.
The purpose of these rules is to try as much as possible to deny patients this surgery because it's just not a good investment for the insurance companies. Obesity takes several years to cause expensive complications and since the majority of U.S. patients don't stay with the same insurance company more than 4-5 years, it means if they pay for your bariatric surgery now they will be helping your next insurance company that will be avoiding to pay for your heart attack and stroke, and that's not something they like to do because their main business strategy is to make money by depriving people of health care whenever they can get away with it.

 

[jwk]

Many insurance policies (almost all BCBS contracts) exclude bariatric surgery under any circumstances, some of them will allow it only if medically necessary and that medical necessity is usually established by the primary physician who is also required to provide additional information like the patient's weight over the past 6 years and the patient's attempts at weight loss.

Thanks for clarifying that. That part makes sense. I was thinking strictly along the lines of "clearing" the patient pre-operatively from a medical standpoint, which is different than what you've laid out.

 

[Tenesma]

1) Filter07: no.... surgeons don't understand risks for the most part... nor do they pay much attention to risk-stratification.... the last person who should decide/understand whether a patient is medically "cleared" or who understands the ramifications of post-operative care is the surgeon.... now if the surgeon is critical-care board certified and has some understanding of pre-operative cardiac evaluation, then it is a different story... very few of those exist.... in fact, most surgeons in the real world don't even WANT to get involved in this..... plus when they send their patients to the internist for "clearance" it equals another billable consult for the internist... a way of padding each others pockets and keeping referral patterns

2) tell patient to get 2nd opinion

3) i really don't care what internists/FPs say re: medical clearance... i'd rather have the cardiologist or the anesthesiologist evaluate the patient ahead of time...