Preoperative Medical Consultation—Questioning a Long-Standing Practice

Abstract

To the Editor Dr Beckerleg and colleagues observed that preoperative medical consultations were not associated with a reduction but rather with an increase in adverse postoperative outcomes. 1 Unfortunately, from the article we learn little regarding the indications, quality, or results of these preoperative medical consultations. Although the findings are possible, concluding that preoperative medical consultations as causative rather than an association with patients who are sicker lacks plausibility. We have difficulty constructing a mechanism whereby preoperative medical consultations could be associated with several of these outcomes.As part of the "perioperative surgical home," the concept of preoperative anesthesia evaluation emerged to avoid same-day cancellations and improve surgical efficiency. The idea was to identify disorders, verify or assess known disorders, and formulate a personalized anesthesia and/or perioperative plan. 2 During the past decade, this practice has been standardized and adopted in some form by many anesthesia practices. Several studies have documented the benefit of this adoption. 3,4 However, this must be distinguished from the indiscriminate protocolized testing or preoperative medical consultations conducted by an internist, as described in the current study.The present study measured preoperative medical consultations as a categorical variable. 1 It did not measure their indication, whether they resulted in an intervention, or the outcomes of any intervention. For example, prompted by a preoperative medical consultation, a patient may undergo a cardiac stress test. Does the patient then receive an intervention to address any concerns in the test results? If yes, was it a successful intervention? Understandably, this degree of granularity may not be discerned from the administrative data, and this challenge continues to make assessing the value of preoperative medical consultations elusive. In other words, patients referred by renowned physicians to confident surgeons may never receive preoperative medical consultations. Moreover, patients referred for a preoperative medical consultation to evaluate a specific symptom or medical issue would be more likely to receive value from it than patients referred because of a protocol or routine.Efforts at "perioperative surgical home" and "enhanced recovery after surgery" will only improve patient outcomes if they are characterized by focus, efficiency, and multidisciplinary collaboration. 5 We oppose routine preoperative medical consultations, when there is no specific concern or indication. We advocate asking focused questions considering the surgery in context whenever we request a preoperative medical consultation. This can help make a personalized plan, balance a delay of surgery to permit optimization vs directly proceeding to surgery, and allow for medical adjustments to take place in the postoperative period.