ROLE OF THE PRIMARY CARE PHYSICIAN OR CONSULTANT
The role of the primary care physician or consultant is not to
select or suggest anesthetic or surgical methods but rather to optimize the patient's
preoperative and preprocedure status regarding conditions that increase the morbidity
and mortality associated with surgery.
Quotations and a table in a Medical Knowledge
Self-Assessment Program published by the leading organization representing
internists, the American College of Physicians, highlight this role for the consultant:
[2]
Consultation practice is an important component of virtually every internist's
professional activity and in some specialties accounts for up to 50% of patient care
time. Effective interaction with colleagues in other specialties requires a thorough
grounding in the language and science of these other disciplines as well as an awareness
of basic guidelines for consultation [Table 27-1]. ... The consulting internists'
role in perioperative care is focused on the elucidation of medical factors that
may increase the risks of anesthesia and surgery. ... Selecting the anesthetic
technique for a given patient, procedure, surgeon, and anesthetist is highly individualized
and remains the responsibility of the anesthesiologist rather than the internist.
TABLE 27-1 -- Guidelines for consultation practice
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1. Complete a prompt, thorough, generalist-oriented evaluation. |
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2. Respond specifically to the question(s) posed. |
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3. Indicate clearly the perioperative importance of any observations
and recommendations outside the area of initial concern. |
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4. Provide focused, detailed, and precise diagnostic and therapeutic
guidance. |
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5. Emphasize verbal communication with the anesthesiologist and
surgeon, particularly to resolve complex issues. |
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6. Avoid chart notations that unnecessarily create or exacerbate
regulatory or medicolegal risk. |
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7. Use frequent follow-up visits in difficult cases to monitor
clinical status and compliance with recommendations. |
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From American College of Physicians: Medical consultation.
In Medical Knowledge Self-Assessment Program IX,
Part C, Book 4. Philadelphia, American College of Physicians, 1992, p 939. |
Optimizing a patient's preoperative and preprocedure condition
is a cooperative venture between the anesthesiologist and the internist, pediatrician,
surgeon, or family physician. If the primary care physician cannot affirm that the
patient is in the very best physical state attainable (for that patient) by that
physician and his or her consultants, the anesthesiologist and physician should do
what is necessary to optimize that condition. Failure to consult with the primary
care physician preoperatively or before a complex procedure is as risky as not checking
the oxygen in the spare tanks. In fact, statements that describe the preoperative
and preprocedure physical condition of the patient (e.g., "This patient is in optimum
shape" and "I believe the mitral stenosis is more severe than the slight degree of
mitral insufficiency") are much more useful to the anesthesiologist than statements
that suggest overall clearance ("cleared for surgery") or perioperative procedures
("prevent hypoxia and hypotension").
Primary care physicians can prepare and treat a patient to provide
optimal conditions for daily life. However, they do not have the depth of understanding
of the anesthesiologist regarding the physiologic changes brought on by surgery and
the manipulations in function that must be made to facilitate surgery and procedures
and optimize perioperative and periprocedure outcomes. One example would be the
induction of some degree of prerenal azotemia in a patient with congestive heart
failure (CHF) by the primary care physician. The volume depletion associated with
prerenal azotemia may make a cardiac patient more comfortable in daily life but would
predispose that patient to hypovolemic disaster during and after surgery and complex
procedures. Thus, even though it would be desirable for the primary care physician
to start the process of preparing the patient for the needs of surgery or complex
procedures, this activity would not be compatible with the current state of knowledge
or functioning of the vast majority of primary care physicians. Although such education
is more readily available and of better quality than in previous decades[3]
[4]
[5]
[6]
[7]
and although Fleisher, Goldman, Charlson, and
their coworkers and even cardiologic organizations have provided considerable data
regarding the importance of this aspect of care,[7]
[8]
[9]
[10]
the training, knowledge, and ability of primary care physicians are still very deficient
in this aspect of consultation. Without understanding the physiologic changes that
occur perioperatively, it is difficult to prescribe the appropriate therapy. It
is therefore part of the anesthesiologist's job to instruct the patient's consultants
about the type of information needed from the preoperative and preprocedure consultation.
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