Home >Newsletters >November 2002>The Anesthesiologist as Perioperative Physician
 
 ASA NEWSLETTER
 
 
November 2002
Volume 66
Number 11

The Anesthesiologist as Perioperative Physician: The PCP of the Preoperative Period?

David L. Hepner, M.D.

Anesthesiologists are becoming accustomed to the concept of the perioperative physician. The concept of the perioperative physician starts in the preadmission test center. These centers see the majority of surgical cases since very few patients are admitted prior to the day of their procedure. Anesthesiologists review the medical history, perform a physical examination, order tests as necessary, decide whether to order consultations with specialists and evaluate the patient’s readiness for surgery. Outside consultants and the patient’s primary care physician may give feedback to the anesthesiologist, but the decision about whether to proceed with an elective case is the anesthesiologist’s.

Primary care providers (PCPs) see patients for routine visits, order tests and consults as necessary and coordinate the final disposition of the patient. How does this differ from the role of the anesthesiologist as a perioperative physician in the preoperative period? One could argue that there is little to no difference between what PCPs do and what we do during the perioperative period. Basically, perioperative physicians must prove that patients are medically stable and optimized for the proposed surgical procedure.

You may ask yourselves, what then prevents primary care providers from taking over our job as preoperative physicians? The answer is quite simple. Anesthesiologists have specialized training in risk assessment and understand very well the “black box” of the intraoperative period. We understand the interactions of anesthetics with disease processes and the hemodynamic changes and fluid shifts of different surgical procedures.

Difficulty arises not in being able to do a good job getting patients ready for surgery but in convincing our surgical colleagues and hospital administrators that we can do this job well. Surgeons have to abandon the idea of ordering consults in order to avoid cancellations by anesthesiologists. In comparing two three-year periods, we reduced the number of cardiology consultations threefold by instituting procedural, educational and staffing alterations in our preadmission test center.1 Patients with coronary artery disease do not automatically get a cardiology consult. If the patient is followed closely by a cardiologist, we obtain existing information and assess the stability of cardiac disease and the need for additional evaluation. According to current recommendations, if a patient has had a stress test within the past two years or a coronary artery bypass graft within the past five years and has no new signs or symptoms of coronary artery disease, no additional cardiac workup is necessary.2

“The timing of the preoperative visit is very important, especially for patients with complex medical histories. It is essential that we see these patients in advance.”


Support of hospital administrators is as important as the support of our surgical colleagues. Although it is possible to bill for some of these complex visits, there must be documentation that this was not a routine preoperative evaluation. Brigham and Women’s Hospital currently provides financial support for two attending anesthesiologists and a nurse anesthetist. In addition, the hospital pays for the nurse practitioners who work in our facility. Not too long ago, I was sitting at a meeting with hospital administrators and physician representatives of a major insurance carrier in Massachusetts. Our preadmission test center found that some of the “complete” packages they were sending to us had missing information or “patient clearance” of an unstable patient. The medical and surgical representatives of that insurance carrier, both physicians, acknowledged that their primary care physicians were not trained in the relatively new field of risk assessment. They agreed to let us decide which patients needed further workup or consultations and to bill those complex patients as an anesthesia consult instead of bundling the preoperative assessment in the subsequent anesthetic reimbursement.

The ordering of blood work, electrocardiograms and chest X-rays is another area that should be shifted to the preoperative physician. Shifting the ordering of preoperative tests from surgeons and primary care physicians to anesthesiologists brought a 55.1-percent decrease in ordered tests, translating into a 59.3-percent hospital cost-reduction, or $112.09 per patient.3

Close coordination between the preoperative anesthesiologist and the intraoperative anesthesiologist is of the utmost importance. Miscommunication between members of our team causing cancellations of surgeries may lead to surgeon dissatisfaction and a return to the ordering of unnecessary tests and consults in an effort to ward off the potential of a cancelled case.

The timing of the preoperative visit is very important, especially for patients with complex medical histories. It is essential that we see these patients in advance. At the Brigham and Women’s Hospital, we recently instituted a policy that all patients should be seen at least 48 hours prior to the surgical procedure if at all possible. This allows us enough time to review the history and any additional information from the patient’s PCP or specialists and decide whether the patient needs any further evaluations. If additional workup is necessary, we attempt to obtain it without having to postpone the surgery. Our goal is not just to obtain enough information to get the patient through the surgery but to ensure that the patient is medically stable.

The role of the anesthesiologist as the perioperative physician encompasses more than just evaluating and stabilizing medical issues. Patients presenting for preoperative workup have significant anxiety about their upcoming procedures. It is essential for the preoperative clinician to spend time with the patient explaining the anesthetic and postoperative pain control options. In a recent article outlining what outpatients value most during their anesthetic care, Fung and Cohen demonstrated that information and communication were ranked the highest by patients.4 In preoperative care, patients preferred that anesthesiologists identify and address their concerns.4 Anesthesiologists underestimated the value placed by patients on information and communication.4

“The role of the anesthesiologist as the perioperative physician encompasses more than just evaluating and stabilizing medical issues… It is essential for the preoperative clinician to spend time with the patient explaining the anesthetic and postoperative pain control options.”


It is important that anesthesiologists as perioperative physicians develop verbal and nonverbal strategies to communicate better with patients. Many recent articles in well-known anesthesia journals have stressed the concept of communication skills for anesthesiologists.5-6 We cannot evolve into perioperative physicians without first ensuring that we are developing and improving our communication skills. Nonverbal forms of communication include manners, habits, appearances and interpersonal skills.6 Mark J. Lema, M.D., Ph.D., editor of the ASA NEWSLETTER, received a great deal of criticism when he suggested that we as anesthesiologists should dress as professionals whenever we are outside of the operating room.7-8 I completely agree with Dr. Lema, especially when we are seeing patients in preoperative test centers.

The recent “Practice Advisory for Preanesthesia Evaluation” developed by the ASA Task Force on Preanesthesia Evaluation states that the preanesthesia evaluation is the responsibility of the anesthesiologist.9 It further states that this evaluation includes the history and physical examination and a review of medical records and tests.9 It also stresses the option of obtaining additional consults and the use of information obtained during the preoperative visit to educate the patient.9 In my opinion, this practice advisory not only supports the concept of the anesthesiologist as the perioperative physician but also as the primary care provider of the preoperative period.

My former chair, Simon Gelman, M.D., Ph.D., a mentor to many inside and outside of our department and an insightful and experienced physician, once said that the complete transformation from a department of anesthesiologists to a department of perioperative physicians will take time, perhaps even a generation or two of physicians. He also stressed that our educational programs will have to be expanded in order to achieve this goal. He would be happy to read the August 2000 ASA NEWSLETTER article by Orin F. Guidry, M.D., that mentioned recent discussions attempting to modify the anesthesia residency in order to improve its educational content, particularly in subjects outside of the operating room.10 To transform ourselves into a department of perioperative physicians, it is essential that we train this new generation of anesthesiologists about the crucial value of the preoperative visit and the vital importance of good communication skills.


References:

1. Tsen LT, Segal S, Pothier M, et al. The impact of alterations in a preoperative assessment clinic on reducing the number and improving the yield of cardiology consultations. Anesth Analg. (In press)

2. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery-executive summary. Anesth Analg. 2002; 94:1052-1064.

3. Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology. 1996; 85:196-206.

4. Fung D, Cohen M. What do outpatients value most in their anesthesia care? Can J Anesth. 2001; 48:12-19.

5. Smith AF, Shelly MP. Communication skills for anesthesiologists. Can J Anesth. 1999; 46:1082-1088.

6. Kopp VJ, Shafer A. Anesthesiologists and perioperative communication. Anesthesiology. 2000; 93:548-555.

7. Lema MJ. The emperor’s new clothes. ASA Newsl. 1998; 62(9):1.

8. Lema MJ. A tale of three men…or…has your GQ subscription expired? ASA Newsl. 2000; 64(12):1, 36, 37.

9. Pasternak LR, Arens JF, Caplan RA, et al. Practice advisory for preanesthesia evaluation. A report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2002; 96:485-496.

10. Guidry OF. Taking a microscopic view to improve patient care. ASA Newsl. 2002; 66(8):2.   


    David L. Hepner, M.D., is Assistant Professor in Anesthesia, Harvard Medical School, and Assistant Director, Pre-admitting Test Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.
David L. Hepner, M.D.

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