ABBOTT AND COSTELLO’S OPINION ON MEDICAL CLEARANCE FOR SURGERY: Don’t Check the Box!

By JOSEPH F. ANSWINE, MD, FASA

So, what does a comedy skit about baseball from 1938 have to do with medical clearances? Pretty much nothing, but this is an editorial so let’s give it a shot.

First a true story. I had a nice lady in front of me for a major surgical procedure. I am an anesthesiologist by trade for those lucky enough not to know me. She had significant co-morbidities including age, morbid obesity, diabetes poorly controlled by A1C, HTN, and mild aortic stenosis based on an echocardiogram from over two years previously. The patient had very limited mobility which she felt would be resolved by the planned procedure.

There was a medical clearance on the chart, which was a form letter from the surgeon consisting, for the most part, of check boxes stating medically cleared, yes or no. The “yes” box was checked and a signature by a nurse practitioner followed.

This is a classic Abbott and Costello triple play. Who’s on first. Who is this patient? I have learned very little from the clearance form. What’s on second. What has been done to evaluate and optimize this patient? I Don’t Know is on third. There is a collaborating physician out there that possibly does not know that he/she has taken responsibility for stating that this patient is fit for the planned procedure.

I cancelled the surgery for Today (catcher), and maybe, based on the consults and workup performed, it can be done Tomorrow (pitcher). Why (left field) did I cancel the surgery? Because (center field) even though I had a “medical clearance” on the chart, I learned nothing from it and the patient was not likely optimized. Many were upset by my decision but truthfully, I Don’t Give A Darn (short stop).

Asking a consultant for a “clearance” prior to surgery is of little benefit to the patient, surgeon, or anesthesiologist unless it is interpreted as asking for history, need for further studies and optimization. Or, of course, if you want to share liability for a poor outcome.

I am comfortable in saying that it is the very rare doctor that wants to spread liability. The thought is to just “stay in your lane” and let others with differing expertise make clearance determinations. The problem is that the surgeon and anesthesiologist are still ultimately responsible along with the consultant for the outcome of the procedure. Therefore, if we choose to share the responsibility, we should also share the needed information to provide for the best overall outcome surgically and medically.

Many are tired of the term “ERAS” or “Enhanced Recovery after Surgery,” but one of the major tenants is shared knowledge and expertise to allow for the best possible result. The operating room team wants to know medical conditions that could affect the surgical intervention and recovery as well as what has been done to improve the patient’s chances for success, and the medical team wants to know the invasiveness and risk of the procedure to determine the extent of the workup required and possible post operative medical needs.

I value the consultant that chooses to evaluate and optimize the surgical patient based on the procedure to be performed. And I therefore ignore the check box clearance and rely on my own interpretation of fitness and ability to proceed.

In closing, I hope that some find this helpful but know that it is possible that Nobody (Abbott and Costello never named a right fielder) may read this editorial.