Medical clearance visits

[mumixam]

Why does IM do this? Is determining if a surgery is safe or worth the risk beyond the scope of a surgeon?

I guess it's a CYA thing. Has anyone ever avoided a lawsuit because an internist said the surgery was ok, or vice versa?

Man, I hate clinic

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[2010houston]

It’s not clearance. It’s optimization.

The anesthesiologist taking care of the patient very much wants to know :
- do they have any major cardiac or respiratory issues?
- if so, are they optimized? As in, is their asthma controlled? Are they beta-blocked, if appropriate? Are they on the right HTN Meds?
- do they need a stress test or an echo prior to a major procedure?

We depend on you to optimize a patient for surgery. There’s a big difference in bringing an uncontrolled hypertensive patient with an a1c of 14 and recurrent admissions for aspiration PNA to the OR vs a patient with well controlled HTN, asthma but hasn’t used albuterol in months, a1c 6.9.

We appreciate you and you are important! Please help us too.

 

[mumixam]

It’s not clearance. It’s optimization.

The anesthesiologist taking care of the patient very much wants to know :
- do they have any major cardiac or respiratory issues?
- if so, are they optimized? As in, is their asthma controlled? Are they beta-blocked, if appropriate? Are they on the right HTN Meds?
- do they need a stress test or an echo prior to a major procedure?

We depend on you to optimize a patient for surgery. There’s a big difference in bringing an uncontrolled hypertensive patient with an a1c of 14 and recurrent admissions for aspiration PNA to the OR vs a patient with well controlled HTN, asthma but hasn’t used albuterol in months, a1c 6.9.

We appreciate you and you are important! Please help us too.

That's a good point, I hadn't looked at it like that

 

[Crayola227]

Also it doesn't hurt to have someone with nothing to gain from the surgery decide if the person in question is medically stable and has maximized conservative medical therapy.

 

[rokshana]

Why does IM do this? Is determining if a surgery is safe or worth the risk beyond the scope of a surgeon?

I guess it's a CYA thing. Has anyone ever avoided a lawsuit because an internist said the surgery was ok, or vice versa?

Man, I hate clinic

Not clearance...the only ones that cal “clear” is the anesthesiologist and the surgeon.

these visits are about risk stratification and need for optimization

it’s bad terminology and should be stopped.

 

[Redpancreas]

Why does IM do this? Is determining if a surgery is safe or worth the risk beyond the scope of a surgeon?

I guess it's a CYA thing. Has anyone ever avoided a lawsuit because an internist said the surgery was ok, or vice versa?

Man, I hate clinic

It's just how the work's divided. It also makes sense that the team making the determination is not the surgeon. Several other reasons.

1.) Understanding of medical conditions in terms of their severity, acuity, etc. is not well known oftentimes by surgeons. I had a resident call me telling me a patient was medically complex (SLE-on HCQ, DM on Metformin) and wanted medicine to watch this patient. There was nothing to do besides the whole protocol and tell them what to do with insulin. This isn't always true though. Most good/experienced surgeons have gestalt for this and know the common things. It's still good practice to have the medicine team look at it.

2.) You are right that many things are standardized things.non cardiac, cardiac risk strat, (don't say clear unless you want your attending to give you that lecture), etc. Just learn them. It's good to know for your medical knowledge.

3.) Surgery's a hemodynamic stress on the body (anesthesia/preload) so you need to know what cardiac conditions affect the surgery and Cardiology is a branch of IM afterall.


tl;dr: Head to Toe

1. EATFRee, my own acronym (emergency, ACS, type, functional status, RCRI), insulin, BP meds, what to hold/halve/keep, how to risk stratify. Hold diuretics/ACE the day of, the rest are fine.

2. Pulm risk strat just tells you about resp. insuff and risk of vent after. Doesn't change much. Rarely are PFTs neded.

3. If CKD, watch BP. Dialysis should generally be held in lieu of surgery. Avoid tons of contrast if there is an angio and CKD.

4.) A/C- Depends on the surgery, generally ASA off 7 days, DOACs 3 days.

5. GI/ID: Nada

6. Endo: Half the long acting insulin night before or morning of. Obv no need to for mealtime insulin. metformin should have been dc'ed on admission.

7. Most autoimmune long terms meds can be continued. Some weird rules for 6-MP. Biologics usually stop a week before but some vary.

------------------------------------

Medical Consults Attending: "The smartest physicians in the hospital are they've orthopedic surgeons, they've successfully managed to convince everyone else they don't know how to manage medical conditions.

 

[rokshana]

It's just how the work's divided. It also makes sense that the team making the determination is not the surgeon. Several other reasons.

1.) Understanding of medical conditions in terms of their severity, acuity, etc. is not well known oftentimes by surgeons. I had a resident call me telling me a patient was medically complex (SLE-on HCQ, DM on Metformin) and wanted medicine to watch this patient. There was nothing to do besides the whole protocol and tell them what to do with insulin. This isn't always true though. Most good/experienced surgeons have gestalt for this and know the common things. It's still good practice to have the medicine team look at it.

2.) You are right that many things are standardized things.non cardiac, cardiac risk strat, (don't say clear unless you want your attending to give you that lecture), etc. Just learn them. It's good to know for your medical knowledge.

3.) Surgery's a hemodynamic stress on the body (anesthesia/preload) so you need to know what cardiac conditions affect the surgery and Cardiology is a branch of IM afterall.


tl;dr: Head to Toe

1. EATFRee, my own acronym (emergency, ACS, type, functional status, RCRI), insulin, BP meds, what to hold/halve/keep, how to risk stratify. Hold diuretics/ACE the day of, the rest are fine.

2. Pulm risk strat just tells you about resp. insuff and risk of vent after. Doesn't change much. Rarely are PFTs neded.

3. If CKD, watch BP. Dialysis should generally be held in lieu of surgery. Avoid tons of contrast if there is an angio and CKD.

4.) A/C- Depends on the surgery, generally ASA off 7 days, DOACs 3 days.

5. GI/ID: Nada

6. Endo: Half the long acting insulin night before or morning of. Obv no need to for mealtime insulin. metformin should have been dc'ed on admission.

7. Most autoimmune long terms meds can be continued. Some weird rules for 6-MP. Biologics usually stop a week before but some vary.

------------------------------------

Medical Consults Attending: "The smartest physicians in the hospital are they've orthopedic surgeons, they've successfully managed to convince everyone else they don't know how to manage medical conditions.

It’s a myth that basal insulin needs to be decreased by 50% the night before...this often results in blood sugars > 200 the morning of surgery and then a delay of surgery until the bg is better controlled.

some(many) pts are over basalized because many people will just keep increasing the basal when fasting blood sugars are high.

If the pt is on more that a 50:50 split of basal:Bolus them yes, them may need a reduction of basal insulin, but more like 10-20% reduction, but otherwise if surgical time is < 4 hours, no need to decrease overnight insulin.

if getting basal insulin on the morning, then would consider a reduction ...again more like 20-30% decrease...these pts are more likely getting some meal coverage from their basal insulin and could drop with a surgery time of > 4 hours.

 

[HemeOncHopeful19]

It’s not clearance. It’s optimization.

The anesthesiologist taking care of the patient very much wants to know :
- do they have any major cardiac or respiratory issues?
- if so, are they optimized? As in, is their asthma controlled? Are they beta-blocked, if appropriate? Are they on the right HTN Meds?
- do they need a stress test or an echo prior to a major procedure?

We depend on you to optimize a patient for surgery. There’s a big difference in bringing an uncontrolled hypertensive patient with an a1c of 14 and recurrent admissions for aspiration PNA to the OR vs a patient with well controlled HTN, asthma but hasn’t used albuterol in months, a1c 6.9.

We appreciate you and you are important! Please help us too.

Agree with this 100% and always happy to help optimize a patient or even risk stratify a complicated one/help guide which specialist needs to be involved.

That being said, at least in residency (didn’t go into primary IM) it was not uncommon to get paperwork from a surgeon/anesthesiologist listing a bunch of labs, EKG and CXR they wanted us to order and follow up on as pre-op. They also wanted us to check a box that said “patient cleared for surgery.” The paperwork also said if all of this wasn’t done the procedure would be cancelled.

 

[Redpancreas]

It’s a myth that basal insulin needs to be decreased by 50% the night before...this often results in blood sugars > 200 the morning of surgery and then a delay of surgery until the bg is better controlled.

some(many) pts are over basalized because many people will just keep increasing the basal when fasting blood sugars are high.

If the pt is on more that a 50:50 split of basal:Bolus them yes, them may need a reduction of basal insulin, but more like 10-20% reduction, but otherwise if surgical time is < 4 hours, no need to decrease overnight insulin.

if getting basal insulin on the morning, then would consider a reduction ...again more like 20-30% decrease...these pts are more likely getting some meal coverage from their basal insulin and could drop with a surgery time of > 4 hours.

I believe that. Any evidence (i.e. stuff to show people) who want to just do things by the standard teachings/myths?

 

[IMGASMD]

I want the pcp at least knowing their patient is getting a surgery. Presumably, the pcp knows the patients better than I do. It’s irresponsible for the surgeons just to schedule a case without anyone to see the patient pre-operatively. Their job is to cut, and that’s all they want to do.

It’s unfair to me and the patient when I have to cancel the case at 730 AM, when the patients bp is 230/110 because they didn’t get clear instructions from whoever as to what to take and not to take. Imaging s/he is your grandparent who prepped for days (colon surgery), mentally, arranged rides, and/or took off work..... now the anesthesiologist (me who they’re meeting for the first time) come and say, it’s cancelled because of “hypertensive emergency.” I may push it a little by giving some anti-hypertensive if I have time to manage the patient. But I basically bought the patient when I assume the care by prescribed a treatment. What if I decide to bring your grandparent to the OR, what should the bp be maintained at. Is MAP of 60 good enough? Higher? But if I have something supporting my decision from the pcp or cardiologist, I would certainly feel better medically and medicolegally (that is part of my decision making, whether you like it or not, that’s part of the reality).

Lastly, as primary care, I sure hope by seeing the patient, you get compensated for something hopefully “easy”. I also hope you get a little offended when you get a discharge summary from the hospital/surgeon/hospitalist for your patient, who you didn’t know was having a surgery. They’re your patient, they’re ultimately your responsibility. But that maybe old school.


PS. If you want orthopedic to manage your patient, please Google orthopedic vs anesthesia. I didn’t have any patient that was in a-sys-tolly, but know of a patient who had SAH was pronounced brain death within 96 hours..... ortho, every single one of those 4 days, put the patient as add-on emergency case. Yes they were the smartest people in med school, but they also spent their residency to forget everything they learned.

PPS. The yield of EKG, CXR, and route labs are low, but sometimes you do catch something. I doubt your clinic patients actually pay for those. Obviously, if they’re prohibitively expensive, then you roll the dice, to see if the anesthesiologist will let them through or not.

 

[rokshana]

I believe that. Any evidence (i.e. stuff to show people) who want to just do things by the standard teachings/myths?

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2021 | Diabetes Care | American Diabetes Association

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA's current clinical practice recommendations and is intended to

care.diabetesjournals.org

Look under perioperative care

 

[sunshinefl]

T

15. Diabetes Care in the Hospital: Standards of Medical Care in Diabetes—2021 | Diabetes Care | American Diabetes Association

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes” includes the ADA's current clinical practice recommendations and is intended to

care.diabetesjournals.org

Look under perioperative care
View attachment 337939

View attachment 337938

Thank you! I added this to my collection of resources.

 

[sunshinefl]

Curbsiders had an episode about peri-op medicine that was great. I know also that ACP was advertising a peri-op book recently I considered getting.

The Curbsiders Internal Medicine Podcast: #135 Perioperative Medicine with Dr Avital O'Glasser on Apple Podcasts

Show The Curbsiders Internal Medicine Podcast, Ep #135 Perioperative Medicine with Dr Avital O'Glasser - Jan 14, 2019

podcasts.apple.com

 

[gutonc]

Curbsiders had an episode about peri-op medicine that was great. I know also that ACP was advertising a peri-op book recently I considered getting.

The Curbsiders Internal Medicine Podcast: #135 Perioperative Medicine with Dr Avital O'Glasser on Apple Podcasts

Show The Curbsiders Internal Medicine Podcast, Ep #135 Perioperative Medicine with Dr Avital O'Glasser - Jan 14, 2019

podcasts.apple.com

That was one of my residency classmates. She has really gone to town on peri-op medicine from the IM side of things and done a lot of good work in changing the field from "clearance" to "optimization" as outlined above. Our residency now has a required peri-op medicine rotation because of her work. She's had a ton of support from surgeons and anesthesia too.

 

[sunshinefl]

That was one of my residency classmates. She has really gone to town on peri-op medicine from the IM side of things and done a lot of good work in changing the field from "clearance" to "optimization" as outlined above. Our residency now has a required peri-op medicine rotation because of her work. She's had a ton of support from surgeons and anesthesia too.

That’s awesome (what she has done)! Also, I would love to have a peri-op medicine rotation!

 

[Redpancreas]

That’s awesome (what she has done)! Also, I would love to have a peri-op medicine rotation!

You may very well. At many places it's called Internal Medicine Consults. You can always request the clinic as well.

 

[sunshinefl]

You may very well. At many places it's called Internal Medicine Consults. You can always request the clinic as well.

Yes we have 4 weeks medicine consults in PGY2! I hope it’s really comprehensive and up to date. I also ordered that peri-op book since it’s been on my mind since they were advertising the release.

 

[Redpancreas]

Yes we have 4 weeks medicine consults in PGY2! I hope it’s really comprehensive and up to date. I also ordered that peri-op book since it’s been on my mind since they were advertising the release.

Out of curiosity, why are you so enthusiastic about medicine? That seems like something dumb I'd do.

Medicine consults is generally structured with 1 attending: 1-2 resident ratios. They give it to you second year as by now you should know how to handle basic issues. You'll get the pager and basically surgical services (usually not GS) will page you.

The most common consults are pre-operative evaluations. Someone will have XYZ medical conditions and need optimization for the OR. You'll go through the process and make sure nothing's been missed, tell them to hold/continue a few medications the day of surgery, and go from there. The main thing to know are certain structural heart diseases and obviously ACS are contraindicated due to the vasoactive affects of anesthesia and fluid shifts (blood loss) during surgery. Anytime you want to do cardiac evaluation on an intermediate candidate, you want to ask yourself if it's OK the surgery get done after they have a stent placed. Lots of people overlook that. The Cardiac Risk Assessment For NonCardiac Patient is the highest yield chart. It's on 1-40 of the Sabatine Orange Book/Blue Book (newer edition). EATFRee is the mnemonic I use to remember the order.

 

[chessknt]

It is ironic that IM physicians would really have any say on perioperative medication management given they have exactly 0 experience ever managing a perioperative patient and perioperative research is almost all anesthesia-driven. Anesthesia usually runs these clinics for that reason but the billing on it is trash so whenever someone else wants to get them back in the OR where they generate an entire clinic day's worth of RVUs in an hour of 4:1 supervision they will take it. That being said there is a role for IM in the non-emergent patient where predominantly cardiac issues need to be optimized with varying degrees of nuance. I find that the majority of these consults tend to be either a way to spread liability around in a bad case with no right answers (eg an urgent procedure with a high bleeding risk in a patient who is high risk to take off AC) or a requirement someone came up with somewhere that adds nothing of value to the patient's care except the $$$. Uncommonly there are some patients where conditions IM recognizes and treats that can be actually optimized in a time frame to actually positively impact care but I can't say I saw it very often (eg uncommon rheumatic conditions, myasthenic patients who need antibiotics).

From the pulmonary side these consults are almost universally useless insurance requirements or from scared surgeons. There are pulmonary risk calculator numbers and the usual phase 1 recovery OSA risk nonsense anesthesia already knows about. Rarely I can be helpful when addressing post-operative extubation in neuromuscular weakness patients or ventilation in patients with advanced COPD.

 

[sunshinefl]

Out of curiosity, why are you so enthusiastic about medicine? That seems like something dumb I'd do.

Lol I can’t explain it I just am. But I do also love that you noticed it.

 

[aafisahar]

perioperative medicine is 99% CYA medicine and 1% convince the players not to do surgery (eg 95 year old, severe AS, severe MS, EF 20% going for cholecystetcomy).

Every study that actually aims to improve outcomes perioperatively has come up snake eyes (eg metoprolol, clonidine, aspirin, stress testing, revascularization, amiodarone for post-op afib, etc etc).

 

[IMGASMD]

convince the players not to do surgery (eg 95 year old, severe AS, severe MS, EF 20% going for cholecystetcomy).

And that player certainly shouldn’t be me.

 

[timpview]

Agree. Total waste of time and money and should be done by anesthesia if surgery can’t risk assess their own patients for the surgery that they perform

 

[IMGASMD]

You cannot have it both ways.... either you own the patient or you do not. I cannot tell you how ticked off I am when I see the 70 yo patient for hip/knee and seen pre-operatively by the np or pa in a doctors office. Either you’re “primary” care or you’re not.

I guess what I am trying to say is you cannot crap on mid-levels in one breath and the next you’re complaining these pre-op checks are useless and time wasting so you shouldn’t be bothered to see them.

I do appreciate a good note from Physicians. Just read a note from a cardiologist stating the patient still enjoys gardening, even though he doesn’t exercise. The other day had a patient with open heart surgery last year, but playing tennis almost daily. It shows that YOU the physician actually talked to your patient and know these things demonstrate that the patient has reasonable exercise tolerance; and to justify not getting more tests or give me excuses to cancel cases.

It is part of the responsibility of the primary care physician to “present” the patient to me. (Since I am “only” a consultant as an anesthesiologist, just like in training, to have a nurse call for a consult is disrespectful to me as a physician).

I will also say this, when I was in IM and worked as hospitalist, I also hated the preop visits and think it was a dump from anesthesia and surgery, since I did not appreciate how much better it is for YOUR patient when s/he is seen by someone who actually knows them and take responsibility for their care.

Sure the financial plays a part, but imaging for a minute if I couldn’t get the information that’s needed for me to safely get the patient through the case. Now I am ordering all the tests all over again and sending your patient all over town to be seen or get tested. You’re wasting valuable time and resources for your patient and the system that we all are using. I am sure there’s a cpt code for you to see the patient and I hope you get well compensated for the visit.

It’s dumb, time consuming, and just checking boxes for 30 some yo olds who you aren’t willing to see. Then don’t be bothered when I return the 70 yo who was managed by PA or NP to the clinic/office for better management. You are the doctor, who will need to take the good with the bad or get out of primary care.

 

[chessknt]

You cannot have it both ways.... either you own the patient or you do not. I cannot tell you how ticked off I am when I see the 70 yo patient for hip/knee and seen pre-operatively by the np or pa in a doctors office. Either you’re “primary” care or you’re not.

I guess what I am trying to say is you cannot crap on mid-levels in one breath and the next you’re complaining these pre-op checks are useless and time wasting so you shouldn’t be bothered to see them.

I do appreciate a good note from Physicians. Just read a note from a cardiologist stating the patient still enjoys gardening, even though he doesn’t exercise. The other day had a patient with open heart surgery last year, but playing tennis almost daily. It shows that YOU the physician actually talked to your patient and know these things demonstrate that the patient has reasonable exercise tolerance; and to justify not getting more tests or give me excuses to cancel cases.

It is part of the responsibility of the primary care physician to “present” the patient to me. (Since I am “only” a consultant as an anesthesiologist, just like in training, to have a nurse call for a consult is disrespectful to me as a physician).

I will also say this, when I was in IM and worked as hospitalist, I also hated the preop visits and think it was a dump from anesthesia and surgery, since I did not appreciate how much better it is for YOUR patient when s/he is seen by someone who actually knows them and take responsibility for their care.

Sure the financial plays a part, but imaging for a minute if I couldn’t get the information that’s needed for me to safely get the patient through the case. Now I am ordering all the tests all over again and sending your patient all over town to be seen or get tested. You’re wasting valuable time and resources for your patient and the system that we all are using. I am sure there’s a cpt code for you to see the patient and I hope you get well compensated for the visit.

It’s dumb, time consuming, and just checking boxes for 30 some yo olds who you aren’t willing to see. Then don’t be bothered when I return the 70 yo who was managed by PA or NP to the clinic/office for better management. You are the doctor, who will need to take the good with the bad or get out of primary care.

Can you cite a single example where you were going to do a case and read something in one of these notes that changed your practice for the betterment of the patient? Or do you mean that having the data summarized by the PCP makes you able to get through your preop work faster so you can get out of the hospital quicker at the end of the day?

 

[rokshana]

You cannot have it both ways.... either you own the patient or you do not. I cannot tell you how ticked off I am when I see the 70 yo patient for hip/knee and seen pre-operatively by the np or pa in a doctors office. Either you’re “primary” care or you’re not.

I guess what I am trying to say is you cannot crap on mid-levels in one breath and the next you’re complaining these pre-op checks are useless and time wasting so you shouldn’t be bothered to see them.

I do appreciate a good note from Physicians. Just read a note from a cardiologist stating the patient still enjoys gardening, even though he doesn’t exercise. The other day had a patient with open heart surgery last year, but playing tennis almost daily. It shows that YOU the physician actually talked to your patient and know these things demonstrate that the patient has reasonable exercise tolerance; and to justify not getting more tests or give me excuses to cancel cases.

It is part of the responsibility of the primary care physician to “present” the patient to me. (Since I am “only” a consultant as an anesthesiologist, just like in training, to have a nurse call for a consult is disrespectful to me as a physician).

I will also say this, when I was in IM and worked as hospitalist, I also hated the preop visits and think it was a dump from anesthesia and surgery, since I did not appreciate how much better it is for YOUR patient when s/he is seen by someone who actually knows them and take responsibility for their care.

Sure the financial plays a part, but imaging for a minute if I couldn’t get the information that’s needed for me to safely get the patient through the case. Now I am ordering all the tests all over again and sending your patient all over town to be seen or get tested. You’re wasting valuable time and resources for your patient and the system that we all are using. I am sure there’s a cpt code for you to see the patient and I hope you get well compensated for the visit.

It’s dumb, time consuming, and just checking boxes for 30 some yo olds who you aren’t willing to see. Then don’t be bothered when I return the 70 yo who was managed by PA or NP to the clinic/office for better management. You are the doctor, who will need to take the good with the bad or get out of primary care.

The pcp is not your resident... they do not need to “present” a pt to you.

the pcp can risk stratify but ultimately the ability to “clear” a pt for surgery is up to those directly involved with their surgery.

a person can have well controlled diabetes with an a1c of 6.5%, but if the morning of the surgery the pt has a sugar of 300... the surgeon is m/l gonna say nope...

 

[tylerb1800]

I do not quite understand PCPs complaining about preop visits. There is no "clearance". Risk assess then medically optimize the patient. Give recommendations on what the patient should due perioperatively with their home meds. Easy visit and reimbursement. Pretty much all of these visits are 99214 with some as 99215.

 

[AlbinoHawk DO]

Why does IM do this? Is determining if a surgery is safe or worth the risk beyond the scope of a surgeon?

I guess it's a CYA thing. Has anyone ever avoided a lawsuit because an internist said the surgery was ok, or vice versa?

Man, I hate clinic

Never clear anyone. Just write "patient is stable on XYZ. It's the sole responsibility of the surgical team for any intervention they perform"

 

[chessknt]

I do not quite understand PCPs complaining about preop visits. There is no "clearance". Risk assess then medically optimize the patient. Give recommendations on what the patient should due perioperatively with their home meds. Easy visit and reimbursement. Pretty much all of these visits are 99214 with some as 99215.

I would again ask what gives a PCP insight in to which medications need to be taken or not perioperatively? Has a PCP ever dealt with a perioperative patient to have this knowledge? If an anesthesiologist changed their home antihypertensive regimen postoperatively would that be good too?

 

[rokshana]

I would again ask what gives a PCP insight in to which medications need to be taken or not perioperatively? Has a PCP ever dealt with a perioperative patient to have this knowledge? If an anesthesiologist changed their home antihypertensive regimen postoperatively would that be good too?

You are being obtuse...not sure if this is purposely or maybe you never worked GIM/hospitalist medicine.

you get referrals all the time for medical clearance from surgery... it would be better if they would send for risk stratification, but many time the wording comes as “clearance “...still just gave risk stratification.

and guess what? I, frankly, will have a better idea of what their insulin regimen should be pre/post operatively than most surgeons... since more often than not, their idea of insulin regimen is a sliding scale.
I’m also going to have a better idea of what my adrenally insufficient/panhypit pts need for their steroid regimen pre /intra/post op, unless it’s neurosurg doing pituitary surgery.

There is nothing wrong with asking that the person caring for a medical issue to give the surgeon (and pt) information about what to do with their meds before and after surgery...and the person best to make that decision is the person managing the issue.

 

[chessknt]

You are being obtuse...not sure if this is purposely or maybe you never worked GIM/hospitalist medicine.

you get referrals all the time for medical clearance from surgery... it would be better if they would send for risk stratification, but many time the wording comes as “clearance “...still just gave risk stratification.

and guess what? I, frankly, will have a better idea of what their insulin regimen should be pre/post operatively than most surgeons... since more often than not, their idea of insulin regimen is a sliding scale.
I’m also going to have a better idea of what my adrenally insufficient/panhypit pts need for their steroid regimen pre /intra/post op, unless it’s neurosurg doing pituitary surgery.

There is nothing wrong with asking that the person caring for a medical issue to give the surgeon (and pt) information about what to do with their meds before and after surgery...and the person best to make that decision is the person managing the issue.

I am not being obtuse. Unless you have sat through a case you have never managed a perioperative patient. You don’t understand what the intraoperative hemodynamic and endocrine consequences of your decisions are because you’ve never had to deal with them. Anesthesiology does however and that is why clearance always falls on them. If they think a patient isn’t going to survive the anesthetic plan they will cancel a case. Optimizing pre existing issues is fine but telling people to take xyz the day of surgery should almost never fall outside anesthesiology or a subspecialty in some uncommon scenarios and never in the realm of a generalist.

 

[VA Hopeful Dr]

I am not being obtuse. Unless you have sat through a case you have never managed a perioperative patient. You don’t understand what the intraoperative hemodynamic and endocrine consequences of your decisions are because you’ve never had to deal with them. Anesthesiology does however and that is why clearance always falls on them. If they think a patient isn’t going to survive the anesthetic plan they will cancel a case. Optimizing pre existing issues is fine but telling people to take xyz the day of surgery should almost never fall outside anesthesiology or a subspecialty in some uncommon scenarios and never in the realm of a generalist.

I don't know any PCP who does make day of surgery medication recommendations (outside of telling the oral surgeons when to hold their blood thinners). Is that actually a thing?

 

[rokshana]

I am not being obtuse. Unless you have sat through a case you have never managed a perioperative patient. You don’t understand what the intraoperative hemodynamic and endocrine consequences of your decisions are because you’ve never had to deal with them. Anesthesiology does however and that is why clearance always falls on them. If they think a patient isn’t going to survive the anesthetic plan they will cancel a case. Optimizing pre existing issues is fine but telling people to take xyz the day of surgery should almost never fall outside anesthesiology or a subspecialty in some uncommon scenarios and never in the realm of a generalist.

Dude...I have been specifically consulted the day before surgery inpt and as outpt bu surgeons what the recommendations are for a pts insulin pump, insulin regimen, hydrocortisone desmopressin doses etc...how about you, a nephrologist, stay in your lane and quit telling me what I do or don’t know or do about the endocrine issues that come before and/or after surgery.
It has been quite commonplace for there to be an endocrine consult prior to and after CT surgery for good glycemic control... you may not know that, since....well ...you are a nephrologist.

I am having more sympathy for renal promethus ...smh

 

[chessknt]

Dude...I have been specifically consulted the day before surgery inpt and as outpt bu surgeons what the recommendations are for a pts insulin pump, insulin regimen, hydrocortisone desmopressin doses etc...how about you, a nephrologist, stay in your lane and quit telling me what I do or don’t know or do about the endocrine issues that come before and/or after surgery.
It has been quite commonplace for there to be an endocrine consult prior to and after CT surgery for good glycemic control... you may not know that, since....well ...you are a nephrologist.

I am having more sympathy for renal promethus ...smh

I am Pulm/CCM here and I actually did know about SCIP measures though I have never seen an endocrinologist involved--the CT surgeons all seem to order insulin drips and pushes of dextrose every few hours in a nonsensical contradictory order set but that describes the entire field of postoperative CT surgery care and they don't listen to anyone anyways. I have worked in 3 major academic hospitals and numerous community centers--literally never seen an endocrinologist in any ICU ever except one time when we had a terminal insulinoma who couldn't maintain euglycemia so sounds like you are in a weird place to me but maybe there is regional variation who knows. Where I work now (tertiary regional health center, referral center for hundreds of miles) it is literally impossible to consult an endocrinologist, there is no EMTALA call for them and they are nowhere to be found in the hospital. Neurosurgery manages their own postop endocrine stuff for panhypopit.

My point is unless you have sat on the anesthesia stool and seen what happens intraoperatively you DO NOT understand perioperative consequences of your preop decisions despite what you have been led to believe. Now I agree there is a role for select subspecialty issues (insulin pump definitely being one of them) but a generalist should not be making those suggestions. I think anesthesia understands how to manage glucose and insulin perioperatively better than endocrinology because, again, they have seen what happens in response to their interventions thousands of times in the OR while you haven't.

 

[rokshana]

I am Pulm/CCM here and I actually did know about SCIP measures though I have never seen an endocrinologist involved--the CT surgeons all seem to order insulin drips and pushes of dextrose every few hours in a nonsensical contradictory order set but that describes the entire field of postoperative CT surgery care and they don't listen to anyone anyways. I have worked in 3 major academic hospitals and numerous community centers--literally never seen an endocrinologist in any ICU ever except one time when we had a terminal insulinoma who couldn't maintain euglycemia so sounds like you are in a weird place to me but maybe there is regional variation who knows. Where I work now (tertiary regional health center, referral center for hundreds of miles) it is literally impossible to consult an endocrinologist, there is no EMTALA call for them and they are nowhere to be found in the hospital. Neurosurgery manages their own postop endocrine stuff for panhypopit.

My point is unless you have sat on the anesthesia stool and seen what happens intraoperatively you DO NOT understand perioperative consequences of your preop decisions despite what you have been led to believe. Now I agree there is a role for select subspecialty issues (insulin pump definitely being one of them) but a generalist should not be making those suggestions. I think anesthesia understands how to manage glucose and insulin perioperatively better than endocrinology because, again, they have seen what happens in response to their interventions thousands of times in the OR while you haven't.

Weird...thought you were nephro... nonetheless, it is a bit presumptuous for you, who is neither endocrine nor anesthesia to tell me how well I know how to practice MY specialty.

and frankly, anyone should know how to manage an insulin gtt... because that is basically what is used during surgery...it’s the before and after that are not as intuitive...

and I’ve posted before, it doesn’t necessarily matter what the pre operative status is... if before the surgery, conditions are such that the surgeon and/or anesthesia think the surgery can’t be done safely, they will not do it... no matter what previous risk stratification/clearance is given.

and while I appreciate you pulling out your measuring stick, apparently your “academic “ centers don’t have all the specialties present...the academic centers that I have worked in have had inpt endocrine presence ( otherwise i wouldn’t be there) and have been involved in the icu...though generally not for glycemic control since pretty much the icu just puts them on a gtt protocol...it’s when they throw them back into dka is generally when I get the consult for sugars in the icu...otherwise it’s for thyroid storm or myxedema in the icu.

 

[chessknt]

and while I appreciate you pulling out your measuring stick, apparently your “academic “ centers don’t have all the specialties present...the academic centers that I have worked in have had inpt endocrine presence ( otherwise i wouldn’t be there) and have been involved in the icu...though generally not for glycemic control since pretty much the icu just puts them on a gtt protocol...it’s when they throw them back into dka is generally when I get the consult for sugars in the icu...otherwise it’s for thyroid storm or myxedema in the icu.

I'll let others weigh in (or not) but I would be crucified for transferring a patient for an inpatient endocrine consult. You clearly appear valued at your current institution which is great but I think it is far more common for rheum/endo to stay out of the hospital simply because nearly all inpatient emergent conditions related to their field are manageable without them. Even when I was working at quaternary center with inpatient endo I only saw them the one time in the ICU and none of their recommendations worked because the guy was too far along and he died anyways. We never called them for thyroid ICU issues since the management on them is fairly straightforward....

Back to my original comment however--it is about respect for a specialty's area of expertise. Anesthesiology is the specialty of perioperative management, it doesn't lessen your expertise to admit that their ability to manage every aspect of physiology including the endocrine system in the perioperative setting is better than yours. Which is why I dont think generalists and most of the time even specialists should be saying what patients should or shouldnt do during this period.

 

[rokshana]

I'll let others weigh in (or not) but I would be crucified for transferring a patient for an inpatient endocrine consult. You clearly appear valued at your current institution which is great but I think it is far more common for rheum/endo to stay out of the hospital simply because nearly all inpatient emergent conditions related to their field are manageable without them. Even when I was working at quaternary center with inpatient endo I only saw them the one time in the ICU and none of their recommendations worked because the guy was too far along and he died anyways. We never called them for thyroid ICU issues since the management on them is fairly straightforward....

Back to my original comment however--it is about respect for a specialty's area of expertise. Anesthesiology is the specialty of perioperative management, it doesn't lessen your expertise to admit that their ability to manage every aspect of physiology including the endocrine system in the perioperative setting is better than yours. Which is why I dont think generalists and most of the time even specialists should be saying what patients should or shouldnt do during this period.

Ironic that you post to respect a specialty’s area of expertise... yet you simply don’t respect mine.
Not sure what your investment in holding up anesthesia are the supreme commander of peri operative care... since you are not one... and interestingly enough, the many anesthesiologists on SDN haven’t said the same...

and apparently icu care must be pretty straightforward...since it’s all pretty much mid levels doing it...smh.

things are simple and straightforward...until they are not. Your dunning-Kruger is showing...

 

[sunshinefl]

I'll let others weigh in (or not) but I would be crucified for transferring a patient for an inpatient endocrine consult. You clearly appear valued at your current institution which is great but I think it is far more common for rheum/endo to stay out of the hospital simply because nearly all inpatient emergent conditions related to their field are manageable without them. Even when I was working at quaternary center with inpatient endo I only saw them the one time in the ICU and none of their recommendations worked because the guy was too far along and he died anyways. We never called them for thyroid ICU issues since the management on them is fairly straightforward....

Back to my original comment however--it is about respect for a specialty's area of expertise. Anesthesiology is the specialty of perioperative management, it doesn't lessen your expertise to admit that their ability to manage every aspect of physiology including the endocrine system in the perioperative setting is better than yours. Which is why I dont think generalists and most of the time even specialists should be saying what patients should or shouldnt do during this period.

Okay but anesthesiology only gets the patient like an hour before in pre-op. Yes they are the experts keeping patients stable in surgery. But they are not doing pre-op medical optimization, or navigating days of pre and post-op medication management. It’s not a lack of respect for anesthesia.

 

[tylerb1800]

Okay but anesthesiology only gets the patient like an hour before in pre-op. Yes they are the experts keeping patients stable in surgery. But they are not doing pre-op medical optimization, or navigating days of pre and post-op medication management. It’s not a lack of respect for anesthesia.

Exactly! Anesthesia only sees them preop before rolling to surgery. Maybe u/chessknt is at a really big academic institute that has preop clinic managed by anesthesia but majority of places do not. Anesthesia does not want to do preop visits. They make there money in the OR not in clinic.

 

[IMGASMD]

Exactly! Anesthesia only sees them preop before rolling to surgery. Maybe u/chessknt is at a really big academic institute that has preop clinic managed by anesthesia but majority of places do not. Anesthesia does not want to do preop visits. They make there money in the OR not in clinic.

It’s not “only” about money. It’s about, to me, you’re the “primary” on the patient. If you don’t want that responsibility to “present”/clear/optimize YOUR patient. What does that say about how you treat you job/patient.

 

[sunshinefl]

It’s not “only” about money. It’s about, to me, you’re the “primary” on the patient. If you don’t want that responsibility to “present”/clear/optimize YOUR patient. What does that say about how you treat you job/patient.

I do want that responsibility. We were responding to the other poster who says we should defer it to you, anesthesia.

 

[IMGASMD]

I do want that responsibility. We were responding to the other poster who says we should defer it to you, anesthesia.

And I thank you. I am also responding to those think it’s a ****ing silly exercise.

 

[rokshana]

It’s not “only” about money. It’s about, to me, you’re the “primary” on the patient. If you don’t want that responsibility to “present”/clear/optimize YOUR patient. What does that say about how you treat you job/patient.

Lookee there...an actual anesthesiologist weighing in! Thank you!

 

[Bobblehead]

I've done many pre-operative optimization visits for COPD or whatever pulmonary ailment the patient has. It's a thing and it will continue to be a thing. Sometimes we can be helpful, sometimes it's ticking off someone's checkbox. There's been enough times where I think it was useful I don't see it as an unreasonable practice standard.

 

[tantacles]

This thread is fire.

 

[BorntobeDO?]

I don't know any PCP who does make day of surgery medication recommendations (outside of telling the oral surgeons when to hold their blood thinners). Is that actually a thing?

This is definitely a thing at my residency (medicine recommending meds in our prep note). I have no idea why they want medicine to do it either other than it being scut. Having been on the other side of surgery (prior life to medicine) when a case goes bad tho, I can say with certainty that they are just trying to spread risk/blame with preops. I clearly recall a patient coding and anesthesia trying to say the patient ‘wasn’t moderate risk’ like their preop said.

I am thinking about just refusing preop risk stratification once I am out of residency. If a surgeon or anesthesia thinks a person is high risk, they need to make that call. I’m not taking the people in the OR nor am I willing to accept consequences for something going wrong in the OR. Why should my note be commenting on the risks of surgery vs a patients individual risk? I don’t do surgery, I don’t know complication rates. This is not my lane.
Anyway, if I end up staying as GIM I will just have to decide that later

 

[VA Hopeful Dr]

This is definitely a thing at my residency (medicine recommending meds in our prep note). I have no idea why they want medicine to do it either other than it being scut. Having been on the other side of surgery (prior life to medicine) when a case goes bad tho, I can say with certainty that they are just trying to spread risk/blame with preops. I clearly recall a patient coding and anesthesia trying to say the patient ‘wasn’t moderate risk’ like their preop said.

I am thinking about just refusing preop risk stratification once I am out of residency. If a surgeon or anesthesia thinks a person is high risk, they need to make that call. I’m not taking the people in the OR nor am I willing to accept consequences for something going wrong in the OR. Why should my note be commenting on the risks of surgery vs a patients individual risk? I don’t do surgery, I don’t know complication rates. This is not my lane.
Anyway, if I end up staying as GIM I will just have to decide that later

I don't do risk stratification. I "clear" patients because Ortho is stupid (seriously their forms say "must write 'cleared for surgery' in note").

But what I really do is make sure their chronic diseases are as well controlled as I can make them and get any testing done/referrals that I feel are needed.

Once in a blue moon someone will be sick enough that I advise against surgery. Like the 90 year old guy guy with an EF of 20%, COPD on oxygen, and PAD going in for a knee replacement.

 

[Vandalia]

This is definitely a thing at my residency (medicine recommending meds in our prep note). I have no idea why they want medicine to do it either other than it being scut. Having been on the other side of surgery (prior life to medicine) when a case goes bad tho, I can say with certainty that they are just trying to spread risk/blame with preops. I clearly recall a patient coding and anesthesia trying to say the patient ‘wasn’t moderate risk’ like their preop said.

It is time for a little bit of medical history.

In the "gold old days" when all you needed to do significant surgery (e.g., gastrectomy, colectomy) was to complete a one-year internship, to get patients a surgeon had to "split fees." In other words, the referring "general practitioner" would expect to receive about a third of what the surgeon collected as a "kick back." If a surgeon refused, he would spend his days twiddling his thumbs in the doctor's lounge and maybe doing a "charity" case every once in a while.

It is for this reason that surgeons pushed the AMA and other medical bodies to make "fee splitting" a violation of medical ethics. (And eventually illegal.)

Fee Splitting | AMA-Code

Code of Ethics Opinions pages. Payment by or to a physician or health care institution solely for referral of a patient is fee splitting and is unethical.

www.ama-assn.org

However, at the same time, surgeons - who were almost always in "private practices" and therefore didn't have a dedicated stream of patients - had to convince FM/IM physicians to send them patients as opposed to the guy down the block. This was of course way before the internet and direct marketing to patients, and still when patients were expected to go where their physician told them to.

This was when "medical clearance" was born. A surgeon couldn't give a cash bribe in the form of fee spitting (although this didn't prevent nice Christmas baskets) but he could ask for a "consult" from the original referring physician. Since consults paid very well, and since a "consult" on a patient you knew very well didn't entail the level of work reflected in the fee, this was a new, legal, form of fee splitting.

So the idea of "medical clearance" is a vestigial aspect of the original idea of fee splitting. It was never really intended to provide useful information to the surgeon.

Like many things in medicine, it remains because that is the way it was always done. Or almost always. It was never about providing good healthcare, it was about billing and revenue. As soon as you see it in that light, it begins to make perfect sense.

Now a little bit of medical trivia:

Since I am old, (and now retired), and since I also retired from the military, a medical student asked me about an episode of MASH she had just seen. In it, Frank Burns mocked Hawkeye and Trapper for "learning surgery in a hospital" and they mock Burns for not doing that. She asked, "was that about the academic/community residency program divide?" No, it was because Frank had no formal training as a surgeon at all. Apart from what he picked up in his general intern year. All the rest he learned (poorly) from his father.

Keep in mind that up until the early 70's, most surgery in the U.S. was done by physicians who did not complete a surgical residency. These patients are quickly dying off, but keep this in the back of your mind if you see someone who had an operation prior to 1970 or so. I have seen a couple of patients who report having had an appendectomy, who had the appropriate scars for an open procedure, but still had their appendix. One surgery resident said, "Impossible. No surgeon would ever do that." "Well, yeah, but that is the problem right there."

End of history lesson.