Every primary care provider has been there. A patient comes in requesting a pre-operative evaluation or places a phone call or EMR message expressing the need for “clearance” before having a surgical procedure. Sometimes, we even get a request from the surgeon’s office with paperwork for “clearance.” Time is always, seemingly, of the essence regarding these evaluations, and either the patient or the operating surgeon requests this be done expediently to schedule a procedure or proceed with one already scheduled. All primary care providers know that the fecal matter of medical paperwork tends to roll downhill. Whether it is a request for FMLA, disability, or medical clearance, as suggested above, these tasks are typically always pushed to the primary care provider. Why? I do not know, maybe because we know the patient best. Or perhaps because we continue to be reluctantly willing to do it. With regard to operative clearance, maybe we live in a very medically litigious society, and it makes sense to diffuse perioperative risk over multiple providers. The real reason I do not know. The one thing I do know is that I cannot “medically clear” your patient for surgery.
It is commonly addressed among family physicians/internists, anesthesiologists, and cardiologists that “medical clearance” is a misnomer. The pre-operative evaluation attempts to mitigate the chance of pre-operative and post-operative complications of surgery. It involves a detailed history, physical exam, and chart review to determine a patient’s risk of an adverse event or complication resulting from anesthesia or surgery. This evaluation is necessary. However, the terminology and expectations need to change regarding the information the examining physician can provide. The purpose of the pre-operative assessment is to identify and mitigate risk and give the patient and the operating physician a clear view of the risk being undertaken by both the patient and the operating physician. All too often, I am sent the pre-operative exam form and find at the bottom: “I, (state your name), deem this patient to be medically cleared for (insert surgical procedure.” Under this statement, a signature of the evaluating physician is requested, thus welcoming myself into being liable for operative complications. Saying a patient is “medically cleared” for surgery implies they are risk-free and in no danger of complications when no provider can confidently make that call.
Until the expectations placed on primary physicians become more distinct and reasonable, I will continue to avoid the term “medical clearance” with regard to the pre-operative evaluation. I will, instead, amend every form to delineate the patient’s level of operative risk and provide avenues of improving risk that can be sought before the performance of the procedure.
Michael McCutchen is a family physician.
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