Giving anesthesiologists what they want: How to write a useful preoperative consult
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.
GOOD GUIDANCE FROM THE ACC/AHA GUIDELINES
Our advice here is broadly consistent with the aforementioned 2007 ACC/AHA guidelines on perioperative cardiovascular evaluation for noncardiac surgery.2 The following observation on cardiac evaluations from these guidelines applies to preoperative consults in general:
The purpose of preoperative evaluation is not to give medical clearance but rather to perform an evaluation of the patient’s current medical status; make recommendations concerning the evaluation, management, and risk of cardiac problems over the entire perioperative period; and provide a clinical risk profile that [can be used] in making treatment decisions that may influence short- and long-term cardiac outcomes.2
These guidelines contain a good description of the ideal preoperative evaluation and consult in a short section (Section II, “General Approach to the Patient”)2 that is worthy of wide dissemination.
DISCUSSION
Question from the audience: Many consults are written more for the surgical team than for the anesthesiologists, hence advice such as managing intraoperative diabetes. Isn’t that appropriate?
Dr. Lubarsky: There are a variety of users of the information in a consult note. I focused on the anesthesiologist, but certainly the surgical staff and house staff would benefit from suggestions about postoperative management. However, they would not benefit from suggestions on intraoperative management; surgeons simply do not need this information and the anesthesiologist will have his or her own regimen. But if there is a specific type of insulin infusion that’s been shown to be best in the specific patient at hand, then detailing that obviously is beneficial.
Question from the audience: We all agree that communication is key, but how does the consultant reach the anesthesiologist to find out what he or she wants to know when the anesthesiologist isn’t usually assigned to the case until a day before surgery?
Dr. Lubarsky: If no anesthesiologist is yet assigned to a case, the consultant can discuss the case with the chief of the anesthesiology department. The discussion should be documented in the note. But it’s important that the system be changed so that anesthesiologists are assigned to cases well in advance. I instituted such a policy at my previous hospital. Many hospitals schedule surgeries 3 months in advance, and many anesthesiology departments have schedules made at least 1 month and often 2 to 3 months in advance. The department could assign a specific anesthesiologist to a future scheduled case with ease.
Question from the audience: How do anesthesiologists educate all the various people we rely on for consults when we can’t get them in one place at one time?
Dr. Lubarsky: It’s a challenge. I try many things, such as going to cardiology rounds, but there are always new people coming through. A good monograph or a set of guidelines with examples would help. If each specialty educates the other and speaks at each other’s conferences more often, that should help. Anesthesiologists would benefit from hearing about the challenges medical consultants face; we may not be doing all we can to optimize perioperative care. There’s room for improvement through communication on both sides. I should also emphasize that we’re all trying to do the right thing. Doctors try to be accommodating, but that doesn’t always make for good decisions. Recently a consultant in my hospital did a preoperative stress test on a patient who didn’t need one. When I asked why, he said, “Because the surgeon asked me to.”
Question from the audience: But don’t you agree that many anesthesiologists would like to see that negative stress test, even if a stress test is not indicated by the guidelines? Cardiologists know that the anesthesiologists are often looking for that on the morning of surgery.
Dr. Lubarsky: The point is that physicians should be responsible for what they have expertise in. When I am asked to intubate a patient, my response as an expert in intubation might be, “Actually, he doesn’t need to be intubated right now.” In the case of this unnecessary stress test, the cardiologist probably should have called the surgeon and said, “It’s really not indicated because the patient had a negative stress test 2 years ago, there’s been no change in symptoms and no angina since then, and he operates well above 4 metabolic equivalents. There’s a clear-cut reason not to do it.” If the surgeon still wanted the test done just to be reassured, that’s simply a poor use of society’s resources. We depend on experts to identify the tests that are indicated to evaluate a patient’s disease and not just do tests for the sake of doing them.
