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Collaboration is key, and so often communication is the thing that makes this work. And more often than we like, when communication and connection are lacking, collaborative patient care can suffer.

Just recently, a colleague told me about a patient that they'd been asked to see for pre-operative evaluation for an upcoming surgical procedure being performed by an outside surgeon located in another state. The patient was known to them, and had in fact just recently been seen for another pre-operative visit with that same provider for the diagnostic procedure that had, in fact, led to this new, upcoming, more invasive surgery.

My colleague told me that they'd seen the patient before the initial procedure, reviewed their past medical history, assessed their surgical risk, and made some recommendations about the patient's medical conditions to help the surgeon through the peri-procedural period for this fairly low-risk diagnostic procedure. My colleague had performed the requested testing, including a large battery of labs, an EKG, and a chest x-ray, most of which were felt by them to be unnecessary, but had been insisted on by the surgeon's office.

As requested, all of these medical records from our practice, the notes with their recommendations along with the results from the requested testing, had been faxed to the surgeon's office, and in the interim the patient had undergone the diagnostic procedure without any apparent complications.

"Cleared" for Surgery

A few weeks after all of this, my colleague had received another fax from the surgeon's office, now for this planned, more invasive surgical procedure, with a request that they simply fill out the pre-operative form and fax it back, without seeing the patient, "clearing them" for the surgery.

As most general internists will tell you, we hate the mindset behind the phrase "clearing for surgery", especially when asked to just check the box on the form that says "patient is cleared for surgery." It feels like we should have grown beyond this, that our role is really to assess someone's medical conditions, how well optimized they are, how they might be improved before the surgery, what we might recommend to help mitigate any risks to the patient, and help make sure that the surgery goes okay.

But in this particular case, the surgeon was just asking us to fill out the form based on our previous assessment and let them know that going ahead with the surgery was okay. My colleague called them, and said that if the surgeon wanted them assessed for the surgery, then they should make them an appointment in our office. The surgeon's office replied that they had done all the testing that they needed, and we should just fill out the form that said the patient was cleared, since her medical conditions hadn't changed.

A Few Good Checkboxes?

It reminded me of the climactic final scene from the movie "A Few Good Men", where Tom Cruise and Jack Nicholson are locked in their epic battle as lawyer and witness. Nicholson states at the onset of his testimony that the victim had been in danger, and that was why he was being transferred off the base. Later, Cruise gets him to say that he had given orders that the victim not be harmed and that because his orders were always followed, there was no chance that anyone would disobey those orders. If there is no chance he would be harmed since Nicholson had ordered him not to be, then how could he be in any danger?

In the case of this preoperative surgical evaluation, the surgeon said nothing has changed, just write that the patient is cleared, but if there's no risk to the patient since nothing has changed, why do we need to write something?

The surgeon's office had responded that the state where they were performing the surgery required a history and physical be documented on the patient within 30 days of surgery, but all of that information was contained in the previous note that we sent to them, and someone from their office was probably perfectly capable of filling that information out on the form, copying it from our previous notes.

What they really wanted was someone to check the box.

What Should Be Done

There is often in our pre-operative evaluation a great deal we can do to help the surgeons. We often know our patients best, and when they ask us the right questions, we really appreciate being involved in the care of our patients as they head for surgery.

I love it when a surgeon asks me, "Are these patient's medical conditions optimized? What do we need to change before surgery? Any medications we need to start or stop or adjust, or any tests we need to do? Or do you think it is just not in the patient's best interest to proceed with this surgery at this time?"

On the other hand, when we get a pre-operative form shoved at us, requesting that we copy information from our chart onto their form, it feels like we are doing menial tasks that don't add to the care of our patients. The surgeon's office staff should be able to ask what the patient's past medical and surgical history are, what their allergies are, what medications they take. They know how to ask about cardiovascular symptoms and easy bleeding and bruising, and prior complications from anesthesia or surgeries.

One would hope that, living in the same electronic medical record, we can all build a more collaborative system to take care of patients in the pre-surgical setting, with internists and anesthesiologists and surgeons all working together and communicating -- maybe even having the input of patients themselves brought into the mix. Some of my favorite surgeons have simplified the process to the point where they'll give me a phone call or send me an email or a chat in the patient portal: "Fred, we're taking Mrs. Smith to surgery next week -- think she's okay to go, anything we need to do?" "No, she should be fine. Everything looks great; thanks for taking care of her."

Clearly, there are times when we need to see people -- cases where we may need to do a lot of testing, may need to do some interventions, may need to start or stop medicines, or may even ultimately decide that surgery is just too risky for this patient at this point in their life. And don't get me started on the pre-operative evaluations which read, "Surgery is scheduled for tomorrow, form needs to be faxed over to our office by 1:00 today or the surgery will be cancelled..."

But if we can find a way to do this better, without a lot of last-minute screaming and faxing and finger-pointing, we, the patients, and the surgeons will probably all be a lot better off.

Clear?

Clearly...

Cleared.

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