Overview of the principles of medical consultation and perioperative medicine
- Steven L Cohn, MD, FACP, SFHM
Steven L Cohn, MD, FACP, SFHM
- Professor of Clinical Medicine
- University of Miami Miller School of Medicine
Internists are often asked to evaluate a patient prior to surgery. The medical consultant may be seeing the patient at the request of the surgeon, or may be the primary care clinician assessing the patient prior to consideration of a surgical referral. The goals of this evaluation are to determine the risk to the patient of the proposed procedure and to minimize known risks. These goals are achieved by the following:
●Identifying unrecognized comorbid disease and risk factors for medical complications of surgery
●Optimizing the preoperative medical condition
●Recognizing and treating potential complications
●Working effectively as a member of the preoperative team (including surgical and anesthesia colleagues)
- Devor M, Renvall M, Ramsdell J. Practice patterns and the adequacy of residency training in consultation medicine. J Gen Intern Med 1993; 8:554.
- McKean SC, Budnitz TL, Dressler DD, et al. How to use the core competencies in hospital medicine: a framework for curriculum development. J Hosp Med 2006; 1 Suppl 1:57.
- Levinson W. Preoperative evaluations by an internist--are they worthwhile? West J Med 1984; 141:395.
- Devereaux PJ, Ghali WA, Gibson NE, et al. Physicians' recommendations for patients who undergo noncardiac surgery. Clin Invest Med 2000; 23:116.
- Clelland C, Worland RL, Jessup DE, East D. Preoperative medical evaluation in patients having joint replacement surgery: added benefits. South Med J 1996; 89:958.
- Macpherson DS, Lofgren RP. Outpatient internal medicine preoperative evaluation: a randomized clinical trial. Med Care 1994; 32:498.
- Mollema R, Berger P, Girbes AR. The value of peri-operative consultation on a general surgical ward by the internist. Neth J Med 2000; 56:7.
- Auerbach AD, Wachter RM, Cheng HQ, et al. Comanagement of surgical patients between neurosurgeons and hospitalists. Arch Intern Med 2010; 170:2004.
- Chen LM, Wilk AS, Thumma JR, et al. Use of medical consultants for hospitalized surgical patients: an observational cohort study. JAMA Intern Med 2014; 174:1470.
- Macpherson DS, Parenti C, Nee J, et al. An internist joins the surgery service: does comanagement make a difference? J Gen Intern Med 1994; 9:440.
- Phy MP, Vanness DJ, Melton LJ 3rd, et al. Effects of a hospitalist model on elderly patients with hip fracture. Arch Intern Med 2005; 165:796.
- Vazirani S, Lankarani-Fard A, Liang LJ, et al. Perioperative processes and outcomes after implementation of a hospitalist-run preoperative clinic. J Hosp Med 2012; 7:697.
- Auerbach AD, Rasic MA, Sehgal N, et al. Opportunity missed: medical consultation, resource use, and quality of care of patients undergoing major surgery. Arch Intern Med 2007; 167:2338.
- Wijeysundera DN, Austin PC, Beattie WS, et al. Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med 2010; 170:1365.
- Goldman L, Lee T, Rudd P. Ten commandments for effective consultations. Arch Intern Med 1983; 143:1753.
- Salerno SM, Hurst FP, Halvorson S, Mercado DL. Principles of effective consultation: an update for the 21st-century consultant. Arch Intern Med 2007; 167:271.
- Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med 1983; 74:106.
- Kleinman B, Czinn E, Shah K, et al. The value to the anesthesia-surgical care team of the preoperative cardiac consultation. J Cardiothorac Anesth 1989; 3:682.
- Rudd P, Siegler M, Byyny RL. Perioperative diabetic consultation: a plead for improved training. J Med Educ 1978; 53:590.
- Katz RI, Cimino L, Vitkun SA. Preoperative medical consultations: impact on perioperative management and surgical outcome. Can J Anaesth 2005; 52:697.
- Choi JJ. An anesthesiologist's philosophy on 'medical clearance' for surgical patients. Arch Intern Med 1987; 147:2090.
- Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2009; 120:e169.
- Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. American College of Physicians. Ann Intern Med 1997; 127:309.
- Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:381S.
- Wilson W, Taubert KA, Gewitz M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 115 published online April 19, 2007. www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1 (Accessed on May 04, 2007).
- Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2006; 52:83.
- Cygan R, Waitzkin H. Stopping and restarting medications in the perioperative period. J Gen Intern Med 1987; 2:270.
- Perioperative Medicine - Just the Facts, Cohn SL, Smetana GW, Weed HG (Eds), McGraw Hill, New York 2006.
- Klein LE, Levine DM, Moore RD, Kirby SM. The preoperative consultation. Response to internists' recommendations. Arch Intern Med 1983; 143:743.
- Ballard WP, Gold JP, Charlson ME. Compliance with the recommendations of medical consultants. J Gen Intern Med 1986; 1:220.
- Sears CL, Charlson ME. The effectiveness of a consultation. Compliance with initial recommendations. Am J Med 1983; 74:870.
- Pupa LE Jr, Coventry JA, Hanley JF, Carpenter JL. Factors affecting compliance for general medicine consultations to non-internists. Am J Med 1986; 81:508.
- Ferguson RP, Rubinstien E. Preoperative medical consultations in a community hospital. J Gen Intern Med 1987; 2:89.
- Horwitz RI, Henes CG, Horwitz SM. Developing strategies for improving the diagnostic and management efficacy of medical consultations. J Chronic Dis 1983; 36:213.
- Klein LE, Moore RD, Levine DM, Kirby S. Effectiveness of medical consultation. J Med Educ 1983; 58:149.
- Mackenzie TB, Popkin MK, Callies AL, et al. The effectiveness of cardiology consultation. Concordance with diagnostic and drug recommendations. Chest 1981; 79:16.
- Adesanya AO, Joshi GP. Hospitalists and anesthesiologists as perioperative physicians: Are their roles complementary? Proc (Bayl Univ Med Cent) 2007; 20:140.
- Batsis JA, Phy MP, Melton LJ 3rd, et al. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med 2007; 2:219.
- Roy A, Heckman MG, Roy V. Associations between the hospitalist model of care and quality-of-care-related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc 2006; 81:28.
- Huddleston JM, Long KH, Naessens JM, et al. Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med 2004; 141:28.
- EFFECT ON SURGICAL OUTCOMES
- GENERAL PRINCIPLES
- Needs of the requesting physician
- - Reasons for consultation
- - Implications of clearing a patient
- Performing the consultation
- - Avoiding anesthetic recommendations
- - Avoiding issues not related to the procedure
- - Discussion with the patient
- COMPLIANCE WITH CONSULTANT RECOMMENDATIONS
- Role of hospitalists
- INFORMATION FOR PATIENTS