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Giving anesthesiologists what they want: How to write a useful preoperative consult

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ABSTRACT

Anesthesiologists are the primary users of preoperative medical consultations (consults), but the information in consults is often of limited usefulness to anesthesiologists and the rest of the surgical and perioperative team. The purpose of a consult is not to “clear” a patient for surgery but rather to optimize a patient’s underlying disease states before they are compounded by the insult of surgery. Too often consults provide advice on subjects that are in the realm of expertise of the anesthesiologist—such as the type of anesthesia to administer or what intraoperative monitoring to use—and thus risk being ignored. Consults should instead provide specific data about the patient that are pertinent to the surgery, as well as guidance on preoperative and postoperative disease management.

KEY POINTS

  • Consults that provide pertinent quantitative data about the patient are helpful—eg, the heart rate at which ischemia was exhibited during stress testing and the degree of ischemia.
  • Anesthesiologists do not need assistance with managing intravenous drugs (with the exception of unusual agents), but they can use specific guidance on managing oral medications pre- and postoperatively to best achieve optimization and steady-state concentrations.
  • Pertinent recent information (< 5 years old) from the nonanesthesiology literature should be provided.
  • Medical consultants should arrange for follow-up care for patients with active conditions not addressed by the surgery.
  • Absolute recommendations should be avoided in a consult: the surgical team may have good reason not to follow them, and legal repercussions could ensue. The words “consider” or “strongly consider” usually suffice, except where there is an absolute standard of care.


 

References

The ideal preoperative medical consultation (consult) is useful to the whole surgical team, ensures maximal patient readiness for surgery, and promotes optimal perioperative care of the patient. Too often, however, consults are ignored or, even worse, set the stage for legal problems. This article identifies problems frequently seen in preoperative consults, particularly from the perspective of anesthesiologists, and gives guidance to those who write consults—hospitalists, internists, cardiologists, and other medical consultants—on providing the information that is most needed by those who use them.

A WIDE RANGE OF END USERS

Anesthesiologists are most often the primary users of the information in preoperative consults, but many other members of the surgical and perioperative team benefit from a well-developed consult, including surgeons, intensivists, nurses, and pain management specialists. Most important, patients stand to benefit, as a good consult helps to ensure that the full breadth of relevant patient-specific information is brought to bear to anticipate potential difficulties and promote optimal care.

Purpose of a consult is in the eye of the beholder

The literature on medical consults in the perioperative arena is scant. The only fairly recent assessment of physician attitudes toward the role of consults was reported by Katz et al in 1998.1 These researchers surveyed attitudes about the various perceived purposes of preoperative cardiology consults, and received rather different responses from anesthesiologists, cardiologists, and surgeons.

There was consensus among all three specialties that two particular functions of a consult are important:

  • Treating an inadequately managed cardiac condition before surgery
  • Providing data to use in anesthetic management.

Additionally, all three specialties deemed the suggestion of intraoperative treatment modalities to be reasonably important when such suggestions were specifically included in the consult request, although anesthesiologists assigned less importance to this function.1

In contrast, anesthesiologists considered suggestions about intraoperative treatment generally unimportant when not specifically requested, and they viewed suggestions of intraoperative monitoring and advice on the safest type of anesthesia as even less important. Anesthesiologists also deemed “clearing the patient for surgery” as an unimportant function of the consult. Cardiologists rated all of these functions as more important than anesthesiologists did and in some cases as considerably more important. To many of the survey questions, surgeons responded that a specific purpose of a consult was “neither important nor unimportant.”1 That may be because the surgeon’s purpose in obtaining the consult is often simply to address the concerns of the anesthesiologist, who might otherwise delay or cancel a needed surgery.

Consult deficiencies: Vagueness, illegibility, dictating anesthetic choice

The survey by Katz et al also assessed each specialty’s perceptions of the most common deficiencies of pre­operative cardiology consults. The deficiencies deemed most common were failure to give specific facts, illegible handwriting, and attempts to dictate the type of anesthesia to be used. Anesthesiologists considered each of the deficiencies assessed as occurring more commonly than their cardiologist or surgeon colleagues did.1

The requester–user disconnect

The differing perceptions of preoperative consults by anesthesiologists and surgeons underscore a fundamental problem: the primary requesters of consults (surgeons) are different from the primary users of consults (anesthesiologists).

Ideally, preoperative consults should be requested by anesthesiologists. Unless and until the ordering of consults changes on a wide scale, however, our advice is for consultants to ask the anesthesiologist what he or she needs to know, in addition to any questions directed to the requesting surgeon. Communication between the surgeon and anesthesiologist should be encouraged as much as possible, and consultants should keep both the anesthesiologist and surgeon in mind when writing consult notes.

A final end user: The plaintiff’s attorney

It is wise to keep in mind one more potential user of your consult: a plaintiff’s attorney. A poorly written consult may benefit plaintiffs’ lawyers. Consults should never give absolute instructions; it is better to use such phrases as “Strongly consider…” or “The current literature strongly suggests…” Otherwise, the surgical team is placed in an awkward position if it does not follow your recommendations, even if for good reason. If a certain recommendation absolutely must be followed, then direct oral communication from the consultant to the attending anesthesiologist (or surgeon) is best.

CONSIDER THE PRIMARY USER: WHAT ANESTHESIOLOGISTS ALREADY KNOW

For the purpose of preoperative consults, it is helpful to think of anesthesiologists as experts in acute medical care. Their 4-year training consists of the following:

  • 1 year of internship, often in medicine, including 6 months of basic patient care in the ward or clinic (the last time they will manage chronic disease)
  • 4 months in the intensive care unit (ICU) and 1 month in the recovery room, which yields solid intensivist training
  • 3 months in pain management, covering acute and chronic pain and regional blocks
  • ~24 months in the operating room, often devoted to care of complex problems in surgical subspecialties (obstetric, pediatric, neurologic, cardiothoracic, vascular)
  • 1 month of preoperative screening and consultations (a recent requirement).

An optional fifth year may be spent in a subspecialty.

Since the large part of anesthesiologists’ training is in acute care, they generally do not need advice about the acute treatment of any ailment. Consults should not advise anesthesiologists on subjects in which they have considerable expertise. They already have well-established ideas about addressing hypertension, myocardial ischemia, heart failure, arrhythmias (unless unusual therapies are needed), bronchospasm, glucose levels, and pain in the operating room, so they are apt to ignore advice on such topics.

There are several additional topics in which anesthesiologists have considerable expertise and do not need guidance in consults:

  • Choice of anesthetic type and its impact on outcome
  • Choice of invasive or noninvasive monitoring for any comorbidity and operation
  • Postoperative patient disposition (ie, whether to send a patient home, to the postanesthesia care unit, to the ICU, or to a step-down unit)
  • Impact of optimizing organ function on perioperative outcome
  • Cardiovascular and respiratory physiology
  • Pharmacology of intravenous agents.

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