By DEBRA DAVIDSON, MJ, CPHRM and DAVID L. FELDMAN, MD, MBA, FACS
The term medical clearance is subject to debate in the medical community. Depending on how the term is used, it can have different meanings in different situations. For example, a fitness trainer might require a client to have medical clearance before beginning an exercise program, or a student athlete might need clearance before participating in sports. (For more information on this topic, see our article “Medical Malpractice and Preparticipation Sports Physicals.”)
The term is often used by surgeons requesting a medical evaluation before performing surgery on a patient. In the context of surgery, a medical clearance is, essentially, considered to be an authorization from an evaluating doctor that a patient is cleared, or deemed healthy enough, for a proposed surgery.
Arguably, clearance is an inaccurate description of what is accomplished during a preoperative medical evaluation. Dr. George Marzouka, a cardiologist who is often asked to perform preoperative cardiovascular evaluations on patients prior to elective procedures, believes that “calling a preoperative evaluation a ‘clearance,’ in fact, belittles the purpose of the assessment, and provides little in terms of meaningful information to the surgeon. It misleads patients, and possibly surgeons, by implying a sense of security that is not based on reality.”
Instead, as Dr. Marzouka reminds us, “the purpose of the preoperative evaluation is to assess what medical problems are present and how those problems might affect a person’s operative risk.” It offers the patient and surgeon “some realistic expectations of what complications may arise during and after surgery.… The evaluation is further helpful for determining interventions the patient can do that may lower that risk.”(1)
Evaluate, Communicate, and Document
A preoperative medical evaluation may not be necessary for all patients having surgery. Otherwise healthy patients—often most easily categorized by the American Society of Anesthesiologists’ (ASA’s) Physical Status Classification System as an ASA I or II—don’t usually require a preoperative medical evaluation, subject to the discretion of the surgeon and/or their primary care physician.
For patients with significant comorbidities (ASA III and above) the surgeon who recommends surgery refers the patient for a preoperative medical consultation. It begins with the patient’s primary care physician, who may seek additional consultation from a specialist, such as a cardiologist. It is the surgeon’s responsibility to provide the evaluating physician with up-to-date information about the patient’s medical condition, the type and expected length of surgery, the kind of anesthesia that is anticipated, how long the patient may be immobile, and details about the patient’s rehabilitation and expected recovery period.
Before determining the patient’s risks for surgery, the evaluating physician considers all information and may request additional labs, tests, or other consults. It is possible that recommendations for adjustments to medical therapy may occur to help the patient get to an optimal place for surgery that mitigates perioperative risks. The surgeon and evaluating physician should agree, for example, about which medications to stop preoperatively and which to continue. Anticoagulants are often an issue in surgical claims. If the patient takes anticoagulants, the surgeon and the evaluating physician should agree on the best approach given the individual’s risk factors.
The evaluating physician and/or the surgeon should also make use of a presurgical risk calculator, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator. This allows for a discussion with the patient that is specific to the procedure and includes the individual’s quantifiable risks.
If it is determined that the patient can proceed with surgery, the evaluating physician should communicate the findings to the surgeon verbally and in writing. Document the patient’s medical record with the evaluation and findings and when and how they were communicated to the surgeon.
Occasionally, a high-risk patient will not be able to proceed because the risks of the procedure outweigh the benefits, even with a change in medical therapy. The reason(s) for the denial should be well documented.
In those instances in which a surgical procedure is considered urgent or emergent, the surgeon will need to use his or her best judgment to determine if there is time for a preoperative medical evaluation, an assessment that would typically be performed by an in-hospital medicine physician such as a hospitalist.
Malpractice Liability Considerations
As with any patient-physician encounter, the preoperative medical evaluation should be carefully documented in the patient’s chart (either inpatient or outpatient, depending on the patient’s preoperative status). In some hospitals, a template is used to ensure that all systems are evaluated during this process, and the template also serves as a checklist. As mentioned previously, the decision to have the patient undergo a preoperative medical evaluation is ultimately up to the operating surgeon, though some hospitals and ambulatory surgery centers may have rules and regulations specifying when a preoperative medical evaluation must occur.
As in all medical decisions, there is always a risk of liability to both the surgeon and the evaluating physician should the patient have an adverse perioperative event. The physicians’ use of good medical judgment and documentation of these decisions in the medical record are the best defense against such a claim. This is also true when the surgeon and the evaluating physician disagree about an aspect of perioperative care or even whether the patient should undergo surgery at all. Ultimately, if the surgeon decides to proceed, he or she will need to document the reasons for choosing a course that might differ from the preoperative consultant’s recommendation. This is no different from any other physician consultation when the physician in charge disagrees with the consultant’s recommendation. Deviation from the recommendation requires documentation of the reasons for doing so.
Opportunity for Partnership and Health Improvements
Preoperative medical evaluations are excellent opportunities for patients to gather more information about their health status and obtain recommendations for improved health. Remind patients to take advantage of the opportunity; a medical exam may provide an early warning sign of something serious.
Avoid using the term medical clearance as it is a misnomer implying that the patient is cleared and free of risks. No patient is free of risk, however, when undergoing a procedure. The goals of the preoperative evaluation are to determine the level of risk and to identify opportunities to mitigate risk—with the surgeon and the evaluating physician working together. The decision about whether to proceed with the surgery belongs to the surgeon and the patient.
Debra Davidson, MJ, CPHRM is Senior Patient Safety Risk Manager for the Department of Patient Safety and Risk Management, and David L. Feldman, MD, MBA, FACS is Chief Medical Officer for The Doctors Company and Healthcare Risk Advisors
Marzouka G. Why I do not provide preoperative “clearance”—and neither should you.
The Medical Bag website. medicalbag.com/home/medicine/why-i-do-not-provide-preoperative-clearance-and-neither-should-you/
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.