Why Medical Clearance Is Really a Preoperative Evaluation

The term medical clearance is subject to debate in the healthcare community. Depending on how the term is used, it can have different meanings in different situations. For example, a fitness trainer might require a client to have medical clearance before beginning an exercise program, or a student athlete might need clearance before participating in sports. (For more information on this topic, see our article “Medical Malpractice and Preparticipation Sports Physicals.”)

The term is often used by surgeons requesting a medical evaluation before performing surgery on a patient. In the context of surgery, a medical clearance is, essentially, considered to be an authorization from an evaluating clinician that a patient is cleared, or deemed healthy enough, for a proposed surgery.

Arguably, clearance is an inaccurate description of what is accomplished during a preoperative evaluation. Dr. George Marzouka, a cardiologist who is often asked to perform preoperative cardiovascular evaluations on patients prior to elective procedures, believes that “calling a preoperative evaluation a ‘clearance,’ in fact, belittles the purpose of the assessment, and provides little in terms of meaningful information to the surgeon. It misleads patients, and possibly surgeons, by implying a sense of security that is not based on reality.”

Dr. Marzouka reminds us that “the purpose of the preoperative evaluation is to assess what medical problems are present and how those problems might affect a person’s operative risk.” It offers the patient and surgeon “some realistic expectations of what complications may arise during and after surgery.… The evaluation is further helpful for determining interventions the patient can do that may lower that risk.”¹

Evaluate, Communicate, and Document

Subject to the discretion of the surgeon and/or primary care practitioner, a preoperative medical evaluation may not be necessary for all patients having surgery. Otherwise healthy patients do not usually require a preoperative medical evaluation.

For patients with significant comorbidities, the surgeon who recommends surgery refers the patient for a preoperative medical evaluation. It begins with the patient’s primary care practitioner, who may seek additional consultation from a specialist, such as a cardiologist. It is the surgeon’s responsibility to provide the evaluating practitioner with up-to-date information about the patient’s medical condition, the type and expected length of surgery, the kind of anesthesia that is anticipated, how long the patient may be immobile, and details about the patient’s rehabilitation and expected recovery period.

Before determining the patient’s risks for surgery, the evaluating practitioner considers all information and may request additional labs, tests, or other consults. It is possible that recommendations for adjustments to medical therapy may occur to help the patient obtain an optimal condition for surgery that mitigates perioperative risks. The surgeon and evaluating practitioner should agree, for example, about which medications to stop preoperatively and which to continue. Anticoagulants are often an issue in surgical claims. If the patient takes anticoagulants, the surgeon and the evaluating practitioner should agree on the best approach given the patient’s risk factors.

The evaluating practitioner and/or the surgeon should also make use of a presurgical risk calculator, such as the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator. This allows for a discussion with the patient that is specific to the procedure and includes the patient’s quantifiable risks.

If it is determined that the patient can proceed with surgery, the evaluating practitioner should communicate the findings to the surgeon verbally and in writing. Document the patient’s record with the evaluation and findings and when and how the information was communicated to the surgeon.

Occasionally, a high-risk patient will not be able to proceed because the risks of the procedure outweigh the benefits, even with a change in medical therapy. The reason(s) for the denial should be well documented.

In instances when a surgical procedure is considered urgent or emergent, surgeons will need to use their best judgment to determine if the situation allows time for a preoperative medical evaluation—an assessment that would typically be performed by an in-hospital specialist such as a hospitalist.

Malpractice Liability Considerations

As with any patient-clinician encounter, document the preoperative medical evaluation carefully in the patient’s record (either inpatient or outpatient, depending on the patient’s preoperative status). In some hospitals, an EHR template is used to ensure that all systems are evaluated during this process, and the template also serves as a checklist. As mentioned previously, the decision to have the patient undergo a preoperative medical evaluation is ultimately up to the operating surgeon, though some hospitals and ambulatory surgery centers may have rules and regulations specifying when a preoperative medical evaluation must occur.

As with all clinical decisions, both the surgeon and the evaluating practitioner risk liability if the patient has an adverse perioperative event. The use of sound clinical judgment and documentation of decisions in the patient record are the best defense against such claims.

This is also true when the surgeon and the evaluating practitioner disagree about an aspect of perioperative care or even whether the patient should undergo surgery at all. Ultimately, if the surgeon decides to proceed, he or she will need to document the reasons for choosing a course that might differ from the evaluating practitioner’s recommendation. This is no different from any other consultation when the clinician in charge disagrees with the consultant’s recommendation. Deviation from the recommendation requires documentation of the reasons for doing so.

Opportunity for Partnership and Health Improvements

Preoperative evaluations are excellent opportunities for patients to gather more information about their health status and obtain recommendations for improved health. Remind patients to take advantage of the opportunity; a preoperative evaluation may provide an early warning sign of something serious.

Avoid using the term medical clearance as it is a misnomer implying that the patient is cleared and free of risks. No patient is free of risk when undergoing a procedure. The goals of the preoperative evaluation are to determine the level of risk and to identify opportunities to mitigate risk—with the surgeon and the evaluating practitioner working together. The decision about whether to proceed with the surgery belongs to the surgeon and the patient.

For additional guidance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.