Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine
Medical Management of the Surgical Patient: A Textbook of Perioperative Medicine
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Product Details
| ISBN-13: | 9781107289505 |
|---|---|
| Publisher: | Cambridge University Press |
| Publication date: | 08/15/2013 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| File size: | 15 MB |
| Note: | This product may take a few minutes to download. |
About the Author
Thomas F. Dodson MD is Associate Chairman of the Department of Surgery and Professor of Surgery and Chief of the Division of Vascular and Endovascular Surgery at Emory University School of Medicine, Atlanta, Georgia.
Neil Winawer MD is Associate Professor of Medicine at Emory University School of Medicine and Director of the Hospital Medicine Service at Grady Memorial Hospital, Atlanta, Georgia.
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Cambridge University Press
0521828007 - Medical Management of the Surgical Patient - A Textbook of Perioperative Medicine - Edited by Michael F. Lubin, Robert B. Smith III, Thomas F. Dodson, Nathan O. Spell and H. Kenneth Walker
Excerpt
Introduction
The interchange between physicians discussing a patient’s case has been mentioned in written history since ancient Greece. From the time of Hippocrates, physicians have been encouraged to seek consultation on difficult cases when they were in doubt. They were urged not to be jealous of one another but to realize their own limitations and to use the knowledge of their colleagues to help. “Nor, among physicians, do those who treat by diet envy those who employ surgery, but they even call each other into consultation and commend one another.” It is clear, however, that there were disagreements in those days: “Physicians who meet in consultation must never quarrel or jeer at one another.” There were also “wretched quarrelsome consultations at the bedside of the patient, with no consultant agreeing with another, fearing he might acknowledge a superior.”
Over the next 25 centuries, consultation has had its ups and downs. Much of what was written had to do with the etiquette and ethics of the interaction. In medieval Europe, little changed from ancient times. Physicians were encouraged to ask colleagues for help if needed and to refrain from criticizingeach other in front of non-physicians.
In the fourteenth century, patients were warned against consulting large numbers of doctors because there would be “endless disagreements and different suggestions” and “the patients [would] suffer from lack of care.” The doctor could call in another physician for consultations, but the treatment should be administered by the one knowing the most about the case. Physicians, curiously enough, were warned about consulting with other physicians. “It is better if he have good excuses that he may refuse their demands. He may feign an injury, or illness, or some other likely excuse. But if he accepts their demands let him make a covenant for his work and make it beforehand … Clearly advise the other leech that he will give no definite answer in any case until he has seen the sickness and the symptoms of the patient.” At least the last is sound advice.
The seventeenth and eighteenth centuries brought out the best and the worst in physicians. In Italy, Julius Caesar Claudinius wrote, “There is no part of a Physician’s Office more illustrious than Consultation, because by it alone unlearned physicians are known from the Learned …. And there is nothing that brings greater advantage to the Sick.” Contrast this with the following: “On December 28, 1750, Drs. John Williams and Parker Bennett, of Jamaica, having become involved in a wrangle about their respective views on bilious fever, came to blows, and, the next day, proceeded to a desperate hand-to-hand combat with swords and pistols, which ended fatally for both. It is said that Johann Peter Frank was so disgusted with the behavior of doctors in consultation that he advised the calling in of the police on all such occasions.” Again, in contrast to the brutish behavior in the British colony, John Gregory wrote that “consultation, when required, is to be conducted in a gentlemanly manner. The chief concern is to be the relief of the patient’s suffering and not personal advancement. That is, the duty to one’s patients takes precedence over personal and professional differences.”
During the eighteenth century, there had been (and would continue to be) a great deal of competition between practitioners. At the turn of the nineteenth century, there was much activity in writing about the ethics of medicine, most of which was aimed at avoiding the harmful effect of this competition. Two men in particular bear mention – Johann Stieglitz and Thomas Percival.
In 1798, Stieglitz addressed the problem of the profession’s internal difficulties and the distrust they engendered in the public. Many practitioners were afraid to admit their need for help and thus avoided consultation with more knowledgeable physicians. He encouraged consultation for the good of the patient while exhorting the consultants to treat the consulting physicians as colleagues and with respect that would only improve the public’s view of the profession.
In 1803, Percival published Medical Ethics, a few years after he had been requested to write on the subject by his fellow physicians. Much of the book was devoted to the etiquette of professional interaction, and consultation was addressed in much the same manner as in centuries past: consultation should be obtained to help the patient; no jealousy, competition, or patient stealing should be tolerated; conflict in front of patients was to be avoided at all costs. It is a tribute to the relative timelessness of Percival’s work that much of it was used almost verbatim in the AMA Codes of Ethics in 1847, 1911, and 1912.
In the late 1800s, another problem surfaced in England. A great gap had appeared between the eminent consultants and general practitioners. Although the former, because of superior knowledge and prestige, were able to command high fees from wealthy clients, they apparently continued to see less well-to-do patients for the same fees that were being charged by the general practitioners. This attracted business to the consultants but left the ordinary physicians with much less work and poor incomes. The result, as could have been anticipated, was ill feeling between the groups. The conflict was of such consequence that the British Medical Journal in 1872 was moved to comment entirely against the “great consultants,” who they believed should charge higher fees. This would decrease the burden of the overworked consultants and distribute the workload and the income in a more reasonable manner.
There was great fear among the general practitioners of sending their patients to consultants, because often these patients remained in the care of the more prestigious men whose care was considered better and whose fees were identical. Thus, the patients had no incentive to return to their practitioners. Therefore, in 1886, the Association of General Practitioners was established to try to regulate the relations between these opponents.
In the United States, meanwhile, another problem was developing. In the mid-1800s, many states repealed their laws regulating medicine, resulting in a large influx of quacks and cults. Because of this, a code of ethics restricting competition among doctors was adopted by the medical profession. This code condemned practitioners who did not have orthodox training, who claimed secret medications, and, importantly for consultants, who offered special abilities. (They may have actually had special abilities.) Although the code did much to discourage unqualified practitioners, as medical practice moved into the twentieth century, it allowed ill feeling to exist between general practitioners and a growing group of medical “specialists.”
A number of other negative results surfaced. Because the code forbade consultations with unlicensed physicians, if a patient insisted on a consultation with an outsider, the legitimate physician was forced to withdraw from the case, leaving the patient in the hands of these unqualified people. The rules also provided an opportunity for exclusion of even qualified physicians, and in the late 1800s, women, blacks, and those who were trying to specialize were at times subjected to these consultation bans.
In the twentieth century, laws have again been passed reducing the numbers of unqualified practitioners. The International Code of Ethics encourages consultation in difficult cases. The attainment of equal status by osteopathic physicians is an interesting sidelight to these ancient struggles to protect patients and the profession.
Today, the problem is entirely different. In previous centuries, consultation was requested from a physician who, although similarly trained, was thought to be more knowledgeable overall. Even 60 years ago, in “uncomplicated” cases, consultation was generally considered unnecessary. The doctor who took care of the patient was the doctor who did the surgery, attended to preoperative and postoperative care, and continued to do the “primary care” long after.
For the past few decades, however, as medical knowledge has mushroomed and physicians have specialized and subspecialized, these tasks have been divided and subdivided. This division of labor has helped the great advances in medicine in the United States, but it also has created some special problems.
The proliferation in consultative medicine has allowed patients to have a large number of experts taking care of each separate part of an illness. The internist asks the cardiologist to consult on myocardial infarctions; the cardiologist asks the endocrinologist to consult on patients with diabetes; the surgeon asks the internist for help on patients with hypertension and congestive failure. Although this accumulation of expertise is impressive and would seem to lead to the best care possible, it can, and not infrequently does, lead to conflicting orders, incompatible medications, and conflicts between consulting physicians. Unfortunately, these conflicts are at times perceived by the patients and can cause unnecessary insecurity, fear, and anger.
These kinds of problems are common in the perisurgical patient who has complicating medical problems before surgery or who develops complications afterward. The surgeon frequently needs to have medical support to help with the complicated problems of preoperative and postoperative care. Unfortunately, the internist’s knowledge of the surgical procedures, the recovery course, and complications is often scanty. This sets up a situation in which each physician has knowledge that the other needs to take optimal care of the patient.
The advantages of the primary care physician, although they should be obvious, have been lost in the tangle of subspecialization. This physician can be either the internist or the surgeon. The important concept is that the responsibility for the integration of therapies falls to that one physician because he or she is most familiar with all aspects of the patient’s case. All other physicians must function as advisors (consultants) to the primary care provider.
The consultant’s role can be a difficult one. It is imperative that the primary physician be aware of, and approve of, all therapy, and therefore feel free to accept and reject the advice of the consultant. Rejection is, thankfully, an unusual occurrence. Under ideal circumstances, it is best for the consultant to discuss all recommendations with the primary physician before they are written in the chart. In this way, information can be exchanged, theories can be discussed, and a mutually satisfactory plan of treatment can be formulated. This avoids the confusion, anger, and mistakes that can occur when the consultant must institute therapy without discussion; this should be done only in an emergency situation, when delay would cause harm to the patient.
Another area of potential difficulty for the consultant is in discussing plans and diagnoses with patients who are exquisitely sensitive to any discrepancy, real or perceived, between physicians. This can cause misunderstanding and anxiety for the patient, and can require an immense amount of explanation by the primary physician to reestablish the patient’s trust, to help him or her understand what is happening, and to allay his or her fears.
In general, it is best for the consultant to communicate treatment plans through the primary physician. When asked, the consultant can give the patient the broad outline of possibilities to be presented to the primary physician. The consultant should always make it clear that the final decision about what is to be done will be made by the primary physician and the patient.
There seem to be five basic principles behind optimal patient care. The first is the one-patient/one-doctor principle of primary care, or the “final common pathway” to integrate therapies as discussed above. Second, the primary doctor and consultant should trust each other. There needs to be a feeling between them that each one is able to provide something important to the patient’s care. Third, communication is indispensable. If the physicians take the time to talk to one another, confusion, irritation, anger, and mistakes can be avoided. The fourth principle is really a corollary of the third, and that is cooperation. It is the natural extension of communication: if two physicians can talk to each other and each one trusts the other’s judgment and knowledge, they will be able to cooperate, even in areas of disagreement, in taking the best care of the patient.
The final principle that ties the others together is etiquette. As in all human interactions, the way people deal with each other may be as important as the content of the interaction. A brilliant consultation, handled in a brusque and rude manner may be no more useful than no consultation at all. Controversial or optimal therapies begun before consultation with the primary physician will make further interaction difficult. Finally, and worst of all, improper therapy instituted erroneously or because of inadequate information not only will harm the physicians’ relationship but may harm the patient as well.
The art consultation is one that involves many aspects of interaction. The primary physician and the patient must feel that the consultant is concerned not only with the hard scientific facts of the patient’s care from the specialist’s viewpoint but with optimal overall management. The request for consultation is not a carte blanche for management; it is a request for advice in treating some part of the patient’s illness. Thus, the consultant should feel like an invited guest in someone’s house, not the master of ceremonies.
Part 1
Medical management
1
Anesthesia management of the surgical patient
L. Reuven Pasternak
The Johns Hopkins University School of Medicine and Public Health, Baltimore, Maryland
Few aspects of healthcare involve as much simultaneous interaction by different physicians as the management of the patient undergoing surgery. At a minimum, the primary care provider, surgeon and anesthesiologist form a team of three physicians, all of whom bring a different perspective and expertise to the care of the patient. As the medical intensity of patients increases, there is also an increasing number of specialty physicians actively involved in this process.
The intersection of the primary care provider and the anesthesiologist first occurs when the surgeon schedules a patient for surgery. At that point the series of events that culminates in medical evaluation, anesthetic assessment, and perioperative management starts. This chapter will begin with that aspect of preparation of the patient for elective surgery. The greatest detail is spent in this area as this is where, by far, the greatest overlap of expertise and communication occurs. The remainder of the chapter will then briefly cover the standard issues involved in perioperative management. These comments are not so much geared to make the primary care provider an expert in the field but are more designed to provide some familiarity with the environment into which the patient is going. It is assumed that detailed information about anesthesia care is provided directly to the patient by the anesthesia provider and/or preoperative systems.
Preoperative evaluation: preparation for surgery
The importance of this phase of clinical management is indicated by its global nature. As the administration of anesthesia may involve a risk for the patient that equals or even exceeds that of the surgery itself, the preoperative evaluation is a crucial first step that may affect the clinical safety and organizational integrity of the entire surgical system. The preoperative assessment of the surgical patient for surgery poses a formidable challenge. While the relative merits of alternative surgical and anesthetic techniques has been extensively studied and reviewed in the literature and other forums, the issue of appropriate preoperative assessment has often remained ambiguous.
Several issues have combined to cause this previously simple process to become more complex.
- While the surgeon has retained the opportunity to examine and assess the patient before the scheduling of surgery, the anesthesiologist often does not have the same access to the patient that had previously existed with routine preoperative admissions.
- The selection of procedures by third party payers to be done on an outpatient and same day admission basis is generally determined on the presumed complexity of the procedure and not the patient’s other underlying medical problems or potential issues associated with anesthesia. Consequently, the anesthesiologist is often asked to manage patients with complex medical conditions undergoing less complex surgery with little prior information.
- Organized health plans often seek to retain as much of the control of the process as possible, including determining when and where tests and consultations are to be done.
- Many hospitals and surgical units have yet to organize and develop preoperative evaluation units due to the expense of staff and space at a time when financial constraints are increasingly severe.
- There has been no consistent system for risk assessment to determine appropriate preoperative management.
- Multiple professional societies have developed specific and often contradictory guidelines on preoperative evaluation for their members.
To further compound the issues there are multiple strategies and guidelines for assessment of the patient undergoing surgery, often from organizations outside of the anesthesia community and, at times, with little input from anesthesiologists or consideration of anesthesia-related issues.
Philosophy
The purpose of the preoperative evaluation is to identify and reduce the risks associated with anesthesia and surgery. The preoperative evaluation is that portion of the general process that is designed to address issues related to the perioperative management of the surgical patient by anesthesiologists. All preoperative activities, including evaluation prior to the day of surgery, testing, and consultation, should be undertaken only on the reasonable expectation that they will enhance the safety, comfort and efficiency of the process for the patient, clinical staff, and overall system. Decisions concerning preoperative management should be associated with a consideration of how any aspect of the evaluation will affect the management and outcome of the perioperative process. Evaluations and interventions that do not have a demonstrated beneficial effect do not have value to the patient, clinician or manager and should not be undertaken on the basis of custom or convenience.
The preoperative evaluation is therefore a focused assessment to address issues relevant to the safe administration of anesthesia and performance of surgery. The use of this event to perform unrelated general medical screening and intervention should be undertaken only in association with appropriate primary and specialty care support. Only anesthesia staff may determine a patient’s fitness for administration of anesthesia and appropriate anesthesia technique. The performance of a history and physical examination by other healthcare providers does not constitute a clearance for administration of anesthesia but provides information to the anesthesia staff to make that determination. Thus, internists and other specialists do not “clear” patients for surgery. Rather, they provide an assessment of the current health status of the patient, including whether the patient is as optimally managed as possible.
When evaluating patients for surgery, it should be remembered that the anesthesiologist has only a temporary but important relationship with the patient. Patients’ continuing care, including assessment of new or acute exacerbations of chronic conditions, should be done by their primary care providers and associated consultants with whom they will have long-term relationships. Patients should be apprised of the fact that the preoperative evaluation is not a substitute for regular primary care. Requests by patients for performance of tests not deemed necessary for the performance of surgery or administration of surgery should also be referred to their primary healthcare source.
Risk classification
While the purpose of the preoperative evaluation is to reduce risk, current risk classification systems are ill-equipped to provide assistance with patient classification. The first attempt to quantify risks associated with surgery was undertaken by Meyer Saklad1 in 1941 at the request of the American Society of Anesthesiology. This effort was the first by any medical specialty to stratify risk for its patients. Saklad’s system did so based on mortality secondary to the associated preoperative medical condition. Type of anesthesia and nature of surgery were not considerations in this system and the divisions were based on empirical experience rather than on specific sets of data and reflect the techniques and standards of practice as of 50 years ago. Four preoperative risk categories were established ranging from category 1 (least likely to die) to category 4 (highest expectation of mortality).
The current American Society of Anesthesiology (ASA) classification system (Fig. 1.1) is a modification of this work, adding an additional fifth category for moribund patients undergoing surgery in a desperate attempt to preserve life. Numerous studies have demonstrated an association of mortality with ASA Classification independent of anesthetic technique.2–14 However, these data have limited application as it relates to mortality as its sole outcome and is based on anesthetic techniques as practiced more than 20 years ago. Apfelbaum15 and Meridy,16 for example, have noted a lack of correlation between ASA status and cancellations, unplanned admissions and other perioperative complications in outpatient surgery.
Thus, while useful as a broad assessment of preoperative medical status, the current ASA Classification is limited in its ability to truly establish risk or serve as a basis for formulating clinical guidelines without an associated risk index for the surgical procedure. In addition, while concerning itself with the identification of risk, there is a remarkable lack of data delineating outcomes in ambulatory surgery and anesthesia. When the ASA Task Force on Preoperative Evaluation recently issued its recommendations for all preoperative assessment, it initially tried to do so using an evidence-based approach linking specific tests and interventions with designated outcomes. The
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Fig. 1.1. American Society of Anesthesiology (ASA) classification system.
literature in this area for all of anesthesia was such that, of over 1200 articles identified in this area, fewer than 30 fit the criteria for use. Lack of information of sufficient scientific validity mandated that the guideline development had to yield to an advisory that was based on consensus opinion subject to further scientific investigation and validation using evidence-based studies at a future date. For purposes of risk stratification, the ASA advisory adopted a modification of the risk index system for patient medical severity and surgical severity as used by the other most commonly used algorithm for patient preoperative assessment, the AHA\ACC guidelines for preoperative assessment of the cardiac patient for non-cardiac surgery.17
Patient and procedure selection
The nature of patient and procedure selection is a function of medical status, surgical procedure and availability of appropriate postoperative assistance, ranging from home care to intensive care support. While elective surgical procedures are by definition not emergencies, many are nonetheless relatively urgent in nature. The delay of some procedures, such as biopsies for staging of oncology treatments, may unnecessarily delay and inappropriately compromise the care of the patient. Surgeons and anesthesiologists must make a judgment if delay will truly reduce the risk for the patient or merely postpone the inevitable task of dealing with a potentially difficult challenge in the operating room. Finally, while mandates for early discharge by regulatory and managed care groups are based almost wholly on postoperative physiologic status, patient comfort and availability of appropriate assistance at home should be a major consideration in this process. In these circumstances, it is anticipated that the primary care provider will provide insight about the medical status of the patient and assist with optimal stabilization prior to surgery. Advice as to type of anesthesia technique should be deferred to the anesthesia team, who will tailor their technique to the special needs of the patient.
Time of the evaluation
At the current time, over 60% of surgery performed in the United States is outpatient and another 10%–15% is performed on a same day admission basis. For this 70% of the nearly 30 million surgical procedures performed each year, the challenge of appropriate timing and content of the assessment is important and sometimes difficult. Initially, it was a common assumption that a preoperative visit prior to the day of surgery confers some added measure of safety and comfort for patients. On the basis of this assumption, patients were often asked to take the time and expense required to comply with such requirements while hospitals and anesthesiologists had to staff centers able to handle this demand.
Eventually, the literature called this practice into question. Fisher’s study18 demonstrated for outpatients and inpatients that prior preoperative evaluation by anesthesia staff reduced cancellations, tests, and consultations. This study was thus useful in demonstrating the need for a screening mechanism that allowed for patient assessment prior to the day of surgery. However, the assertion that these benefits could be obtained only in a system where all patients visited a preoperative evaluation center was not demonstrated. Some studies demonstrated that no preoperative evaluation visit prior to the day of surgery was necessary for healthy patients undergoing minor procedures.19,20 Some of the most comprehensive work in this area has been by Twersky et al.,21 which indicates that patient evaluations on the day of surgery may be performed in a manner that is safe and effective. However, even in these studies, patients were not stratified by medical status or surgical procedure and were not relevant for the larger patient population managed by most anesthesiologists.
In discussions with major academic and private practice medical center directors, it has been observed by this author that the percentage of patients who required having an onsite visit prior averages about 25%–33%. The preoperative assessment must be a balance between patient convenience and the need to have information available in a timely fashion to allow for planning appropriate preoperative and perioperative management. While the ideal system may include a preoperative evaluation prior to the day of surgery for all patients, the logistics of patient schedules and their often otherwise healthy status makes this ideal impractical and, at times, unnecessary. This point is of significant concern to hospital preoperative evaluation staff who believe that resources may be inappropriately committed to patients with little need of those services to the detriment of others with more extensive medical and surgical issues and with waste of resources needed elsewhere.
The algorithm adopted by the ASA for preoperative evaluation (Fig. 1.2)22 recognizes that there are categories of patients (health individuals for low-risk surgical procedures) for whom a preoperative assessment (consisting of information made available prior to the day of surgery for review) is sufficient. Similarly, there are some individuals for whom assessment prior to the day of surgery is mandated by their medical condition and/or planned surgery. It is difficult to provide a standard recommendation for how ambulatory surgical centers should place its patients into these categories; much depends on the ease of availability and validity of data provided prior to the day of surgery. What is uniformly recommended is that appropriate information should be made available to anesthesia staff prior to the day of surgery to allow for review and appropriate action. An example of conditions for which assessment by anesthesia directed staff prior to the day of surgery is provided in Fig. 1.2.
It is increasingly recognized that the role of the primary care provider is critical in this process. That individual is most familiar with the health status of the patient. Thus, while they are not in a position to “clear for anesthesia,” they are in a position to provide the pertinent medical information prior to the day of surgery that would allow surgical systems staff to determine the need for any additional information or consultation.
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