It’s a Monday morning, and two patients wait expectantly for the cardiologist. Instead, they get me, a fresh resident. “I don’t know why I’m seeing you,” says the first. I bumble through the chart and find a note indicating he has a large atrium on his most recent echocardiogram.
“So, what surgery do you have coming up?” I offer, to get a sense of his understanding, but really, to buy myself some more time at the computer. He tells me something about his bladder. He is, in fact, being evaluated for a lung resection. The medical visit unfolds like this for another thirty minutes — a delicate dance between chart biopsy, vague questioning, and counseling on smoking. In an existential moment, I wondered what, if anything we had accomplished. After all, he left on no new medications, and his surgeons had already booked his stress test for the afternoon. Are preoperative visits like routine physical exams, maintained to make practitioners feel good with minimal benefit to the patient?
At best, the benefits of preoperative evaluation are marginal. At worst, they are deadly. A 2010 retrospective article on medical consultation before major elective noncardiac surgery showed an association with increased mortality and hospital stay, and increases in testing. For every 500 patients, 1 patient was harmed by a consultation, due to over-testing or over-treatment. The criticisms of this article are valid. It is impossible to completely control for confounders, as sicker appearing patients are presumably more likely to be referred for consultation.
Also, the data is taken from the late 90s, when patients were routinely placed on beta-blockers prior to surgery. We now have evidence against this practice. Numerous articles suggest that preoperative cardiology consultations are overused. In a striking study of over 700 consults, over 90 percent of evaluations could be answered by referring to American Heart Association (AHA) algorithm of care.
For internists, this debate is old hat. Thirty years ago, in an attempt to classify cost-effectiveness, a retrospective study favored evaluation, given the $146 total visit cost, a modest amount compared to a $4,000 surgery. But multiply this by millions of yearly elective surgeries, and the cost balloons. So, why does the use of preoperative consultation persist, and what should we do about it?
1. Acknowledge physician bias. Both internists and surgeons operate with an information bias, namely, the tendency to seek information when it will not affect action. This bias is deeply ingrained, but should be confronted head on.
2. Realign financial incentives. As long as each service benefits financially from consultation, referral and acceptance of low-risk consultations will persist. Bundled hospital payments for low-risk elective surgeries would create a disincentive for needless referrals.
3. Risk stratify. For those patients at highest risk, consultation may be appropriate (though not of proven benefit). Use AHA guidelines/algorithm to assess low-risk patients.
My second patient arrives in the waiting room. When I ask about his activity, he tells me he chops trees in Maine on a weekly basis. His exam checks out. We spend the rest of the visit talking about his days in Vietnam and working in the backwoods of Alaska. I then bill for the visit, clicking away at his various co-morbid conditions, racking up a bill he or I will never see.
Tom Peteet is an internal medicine resident.
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