Article

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

Author and Disclosure Information

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).

Pages

Next Article: