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A Monday #Medthread:
#medtwitter colleagues—what gets your BP and HR up the most in terms of delivering “bad news”?
in my #periopmedicine world, it’s telling a patient we might need to postpone or cancel their surgery
So…a #tweetorial to share my learnings over the years
1/x
Take a step back—remember that there’s no such thing as “preop clearance”.
The value added is preoperative evaluation and risk assessment, with patient + procedure-specific optimization
Inherent to this is communicating risk and concerns for it
2/x
The overwhelming majority of patients I evaluate in preop clinic are stable/optimized at the time of my evaluation, though my assessment still adds value by empowering intraop and post-op care, as well as facilitating pre-op patient instructions and empowerment
3/x
Indeed, my intro over the years has evolved to:
“I’m an I.M. physician, and you’ve had a very thorough evaluation with your surgeon to get to this point w surgery scheduled”
(do NOT violate patient trust in their surgeons in terms of them doing an incomplete eval!)
4/x
“Think of our visit today as the icing on the cake”

(yes, I say that sometimes...and then we launch into our discussion)

5/x
“today is the big step back to make sure we know everything we need to know about your overall health, everything we need to know about you to get you through the surgery and your recovery, to EMPOWER your surgeon & anesthesiologist team to take the best CARE of you possible”
6/x
But what is we don’t know everything we need to know?

What if we need to order additional pre-op testing (ex ECHO or stress)?

What is that testing can’t be done soon enough and surgery needs to be postponed or cancelled?

HOW do you counsel a patient about all this??

7/x
“The secret of the care of the patient is in caring for the patient”
any discussion about pre-op testing (with or without delay/cancellation) MUST come from a place of caring, concern, empathy, and compassion for their patient and the reasons they have scheduled that surgery
8/x
A lot goes into scheduling a surgery—planning, finances, and mixed emotions—hopes, dreams, and fears—be it for elective surgery (ex. Hip replacement) or life/limb saving (ex. Malignancy related)

If you’re going to throw a wrench it all that, be prepared!

9/x
In addition to your patient being worried about keeping a surgery date, you’ve thrown in worry about something else—what ever you’re sending them to testing for.

That's a new (potential) diagnosis on top of their surgical diagnosis.

10/x
This breaks down a few more ways.
1—via your comprehensive pre-op eval, symptoms are shared/confirmed (ex. Chest pain/dyspnea)--ie the patients knows they experience them and speaks them out loud

2—asymptomatic, based on exam or other objective info

11/x
1⃣ is easier, though still not easy.

"The chest pain you told me about? We need to look into it"

Recall 2007 ACA/AHA guidelines:
“The preoperative consultation may represent the first careful cardiovascular evaluation for the patient in years or, in some instances, ever.”
12/x
2⃣s harder—ex. The murmur they never knew about, the old buried ECHO abnormality.

Now you’re really sprung a concern on them. You must simultaneously counsel about the reasons to potentially delay surgery AND your new medical concerns.
13/x
Repeat after me:
“I’m worried that we don’t know enough about you to get you through the surgery and your recovery safely. I want to learn more info about your overall health. I want to empower your team to take the best care of you possible…& let your PCP know for later”
14/x
“I’m worried you’re not in the best shape possible for surgery. I know you’ve eagerly awaiting this surgery, and I want to make sure you come through this with far more good from it than any potential harm—that you derive the most benefit possible from it. “

15/x
Example:
"I want you to be up and about enjoying your new knee rather than have to recover from a heart attack"

16/x
If I’m seeing them 2-3 weeks before surgery:
“Hopefully we will know more soon and not have to cancel your surgery date”
but sometimes it’s too soon to get testing done:
“I’m sorry, but I really don’t think proceeding with surgery in 1/2/3 days is the safest thing for you”
17/x
the language can vary based on pre-test probability of prohibitive disease.
Ex. The 2014 ACC/AHA guidelines recommend testing for suspicion of at least moderate valve disease, even though it’s not a contraindication to surgery...

18/x
“I’m hoping is not a barrier to surgery as you’re not having any symptoms that I can link to it…but it's still important that we learn more about you to empower your care--both for the surgery and after the surgery”

19/x
Also
acknowledge the patient, their home team, the reasons they’re having surgery:
-you’re so ready to get this surgery done
-your family has flown into town, filed the FMLA paperwork, rearranged schedules
-the surgery is time sensitive (ex cancer-related??)
20/x
CONCLUSION
❇️Stay compassionate
❇️Stay patient-centered
❇️Explain the medical indications for pursing additional testing
❇️Stay curious about your patient as a person—“I want to learn more about your to take the best care of you possible”

Thank you for reading
21/FIN
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