The value added is preoperative evaluation and risk assessment, with patient + procedure-specific optimization
Inherent to this is communicating risk and concerns for it
“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!)
(yes, I say that sometimes...and then we launch into our discussion)
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??
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
If you’re going to throw a wrench it all that, be prepared!
That's a new (potential) diagnosis on top of their surgical diagnosis.
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
"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.”
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.
“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”
"I want you to be up and about enjoying your new knee rather than have to recover from a heart attack"
“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”
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...
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??)
❇️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