Risk Management



Preoperative Testing and Examination

Paul Weber, JD, OMIC Vice President of Risk Management

Digest, Winter 2004

The need for preoperative medical testing and examination has been studied primarily in the context of cataract surgery, although it applies to many other ophthalmic surgeries. A national survey published in 1995[1] showed that the majority of ophthalmologists, anesthesiologists, and internists routinely order certain tests prior to cataract surgery, generally lab work and ECGs but sometimes chest x-rays and blood clotting studies as well. Even though many physicians in the study did not think the tests were necessary, they ordered them anyway because of hospital or surgery center requirements or their own medicolegal concerns. A subsequent study published in January 2000[2] concluded that routine medical testing before cataract surgery does not improve patients’ health or clinical outcomes. Nevertheless, lawsuits involving surgical complications (especially those related to anesthetic reaction) are difficult to defend if routine tests which might have identified a risk factor were not ordered.

Equally difficult to defend are cases in which tests were performed but the ophthalmologist did not review the results or communicate them to the patient. OMIC’s first large indemnity payment was made in 1990 on behalf of a cataract surgeon who failed to review and notify the patient of an abnormal preoperative chest x-ray; the mass soon metastasized into inoperable adenocarcinoma. More recently, in a non-OMIC case, a jury handed down a $5.1 million verdict against an ophthalmologist who failed to diagnose diabetes or to refer the patient to a specialist after receiving three separate lab studies over the course of four months all showing that the patient had elevated blood glucose levels. The patient eventually had to have a right below-the-knee amputation and a left great-toe amputation.

Q  Are there any exceptions to ordering pre-op tests?

A  Probably not if your hospital or ASC requires them. Because cataract patients tend to be elderly and often have coexisting illnesses, many physicians believe that a medical examination with laboratory testing must be performed before a patient can be considered eligible for surgery. On the other hand, some physicians feel that lab work is unnecessary in a healthy patient with a negative history undergoing straight topical anesthesia without an injection. Anytime an injection is involved, however, a preoperative history and physical examination may be warranted.

Q  How extensive should the preoperative history and physical examination be?

There appears to be a wide variance in how ophthalmologists approach the history and physical. Some ophthalmologists obtain preoperative approval via a telephone conversation with the patient’s internist, general practitioner, or primary care physician (PCP) and will request that the referring physician dictate a note stating that the patient is cleared for surgery. During the call, the ophthalmologist will inquire about recent labs, tests, medications, and health history; for example, a prothrombin time for a patient who has stopped taking Coumadin in preparation for surgery or ECG results on a patient with significant cardiac history. A well-documented discussion with a PCP who has examined the patient recently may suffice to approve the patient for surgery.

Q  May I perform my own pre-op examinations?

A  You may do so if you are able to document continuing proficiency in general medicine; otherwise, it is advisable to refer patients to their PCP. That being said, some ophthalmologists prefer to be involved in the pre-op workup rather than to delegate it entirely to the PCP because it allows them, as the surgeon, to become better acquainted with the patient’s overall health status. In such cases, after discussing the patient’s history with the PCP, the ophthalmologist performs a brief physical exam and orders any tests not recently obtained by the PCP.

Q What steps should I take to ensure that patients are informed of test results?

A  Develop office systems to assure the efficient processing of all diagnostic clinical information, including:
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  • A method for ensuring that lab results, consultation reports, and other pertinent documents are seen by the treating/attending physician before they are filed.
  • A reminder or diary system to ensure that follow-up tasks, such as notifying patients of test results, are undertaken when warranted.
  • A formal arrangement whereby adverse test results or those requiring immediate attention are reported personally by the consulting physician to the requesting physician.

 

1. Bass EB, et al. “Do Ophthalmologists, Anesethesiologists, and Internists Agree About Preoperative Testing in Health Patients Underwgoing Cataract Surgery?” Arch Ophthalmol 1995; 113:1248-1256.

2. Schein OD, et al. “The Value of Routine Preoperative Medical Testing Before Cataract Surgery.” NEJM 2000; 342:168-175.

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#3. Best at defending claims.

An ophthalmologist pays nearly half a million dollars in premiums over the course of a career. Premium paid is directly related to your carrier’s claims experience. OMIC has a higher win rate taking tough cases to trial, full consent to settle (no hammer) clause, and access to the best experts. OMIC pays 25% less per claim than other carriers. As a result, OMIC’s base rates have consistently averaged approximately 15% lower than multispecialty carriers in the U.S.

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