How to Appropriately Assess Risk in a Patient
The term clearance implies that a patient can proceed with surgery and will have no risk for complications — which is a fictional state.
As a cardiologist, I am often asked to perform preoperative cardiovascular "clearance" — whatever that means —on patients prior to elective procedures.
The term clearance implies that a patient can proceed with surgery and will have no risk for complications — which is a fictional state. Unfortunately, there is no such state as being at no risk. In fact, no activity in life is without risk.
I often tell this to my patients by sharing the following examples:
If you were to cross a small street, there is a risk, albeit a small one, of getting struck by a moving vehicle. If you were to cross an eight-lane highway, that risk is obviously much higher. On the other hand, you might think that you can avoid all risk by staying at home in bed all day. But you would still encounter risk — you might develop deep vein thromboses, bedsores, and even lethal infections.
No action in medicine can possibly be without some risk.
Calling a preoperative evaluation a “clearance,” in fact, belittles the purpose of the assessment, and provides little in terms of meaningful information to the surgeon. It misleads patients, and possibly surgeons, by implying a sense of security that is not based on reality. In fact, using the term “clearance” appears to have made it into a tool by which surgeons share or shift liability to internists and subspecialists. So it baffles me why anybody would want to have a preoperative clearance — or why any physician would agree to provide one.
The purpose of a preoperative evaluation is to assess what medical problems are present and how those problems might affect a patient's operative risk. The evaluation is further helpful for determining factors or interventions that may mitigate that risk.
Lastly, and most importantly, the preoperative assessment offers both the patient and the surgeon some realistic expectations of what complications may arise during or after surgery. There are numerous risk calculators available that give a scale of estimated relative risk — such as the Revised Cardiac Risk Index (RCRI), which estimates the risk for having a major adverse cardiovascular event during or after surgery. While providing a numerical risk estimate to patients may confuse a few, most of them appreciate having the information.
Such calculating of risk also gives physicians an opportunity to document that there is an expected risk that is greater than zero. That way, in the unfortunate circumstance of an adverse event occurring, no one can rationally accuse you of “clearing” the patient for surgery.