In Reply:-Kempen maintains that “the single most cost effective preoperative evaluation likely occurs when competent surgeons thoroughly evaluate and prepare their patients regarding perioperative needs…” He later bemoans the concern that Stanford's surgeons “never develop necessary skills…” Implicit in these, and other statements, is an assumption that appropriate preparation of patients for the perioperative period is something best performed by either surgeons or primary care physicians. This is simply not true.
The goal of surgical training is learning when and how to perform surgery. The emphasis is, as it should be, on the diagnosis of surgical disease, selection of the appropriate operation, and skilled performance of that operation. Similarly, primary care physicians and medical subspecialists are trained to deal with disorders within the context of everyday life at home or recovery from a severe medical problem in the hospital. Neither surgeons, primary care physicians, nor medical subspecialists are trained to understand the interactions between perioperative pathophysiology and intrinsic medical conditions. In contrast, anesthesiologists are specifically and intensively trained in just such issues. Therefore, in a sense, Kempen's statement regarding the need for surgeons to develop “necessary skills” is key. Surgeons, primary care physicians, and medical subspecialists will need to develop additional skills to deal with patients in the perioperative period, just as some anesthesiologists may need to enhance their skills in this area, also. However, an anesthesiologist trained in a modern department that emphasizes perioperative medicine possesses these skills in abundance and is, therefore, the appropriate individual to evaluate and prepare a patient for the perioperative period. An analogy to postoperative pain management can be made; the anesthesiologist understands the physiologic source of pain, is versed in management modalities, and is trained to manage these in the context of the response to surgery. Clearly, the anesthesiologist is best equipped to manage this issue, and the failure of classical methods of postoperative pain management emphasizes this point.
Let's put this in completely practical terms. It is the rare anesthesiologist who has not been confronted with a medical consultation for “preoperative clearance,” wherein a well meaning primary care physician, untrained in the implications of perioperative pathophysiology, has neglected an essential component of preoperative management. Similarly, most of us have been faced with a consultation on a significantly ill patient who is “cleared but only for spinal anesthesia,” indicating ignorance of the issues involved. Surgeons tend to treat such consultations as license to proceed and are angered when an unaddressed issue leads to cancellation or postponement. The result is often the ordering of all tests on all patients. Appropriate preoperative evaluation by a competent anesthesiologist, or a physician extender supervised by that anesthesiologist, can avoid these problems. We anesthesiologists are trained to do this, we are better aware than anyone of the issues involved, and anesthesia preoperative evaluation clinics such as that at Stanford will serve to institutionalize this essential role. This may not be the best approach for all places; the private practitioner in a small hospital may accomplish the same thing simply by being available for informal consultation and by developing a professional and personal relationship with his surgical colleagues. The point is, this service is appropriate, and best provided by a well-trained anesthesiologist. Embracing this role is good for anesthesiologists, surgeons, hospitals, and, most importantly, patients.
Clifford S. Deutschman, M.S., M.D., Associate Professor of Anesthesia and Surgery, Director, Fellowship in Critical Care Medicine, Department of Anesthesia, University of Pennsylvania Medical Center, 3400 Spruce Street, Philadelphia, Pennsylvania 19104–4283.
(Accepted for publication September 11, 1996.)