BMC Family Practice BioMed Central

Research article Open Access

An internist's role in perioperative medicine: a survey of surgeons'
opinions
Lisa PausJenssen*, Heather A Ward and Sharon E Card

Address: Department of Internal Medicine, University of Saskatchewan, Saskatoon, Canada

Email: Lisa PausJenssen* - [email protected]; Heather A Ward - [email protected];
Sharon E Card - [email protected]
* Corresponding author

Published: 21 January 2008 Received: 14 May 2007

Accepted: 21 January 2008
BMC Family Practice 2008, 9:4 doi:10.1186/1471-2296-9-4
This article is available from: http://www.biomedcentral.com/1471-2296/9/4
© 2008 PausJenssen et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Literature exists regarding the perioperative role of internists. Internists rely on this
literature assuming it meets the needs of surgeons without actually knowing their perspective. We
sought to understand why surgeons ask for preoperative consultations and their view on the
internist's role in perioperative medicine.
Methods: Survey of surgeons in Saskatoon, Saskatchewan, Canada regarding an internist's
potential role in perioperative care.
Results: Fifty-nine percent responded. The majority request a preoperative consultation for a
difficult case (83%) or specific problem (81%). While almost half feel that a preoperative
consultation is to "clear" a patient for surgery, 33% disagree with this statement. The majority
believe the internist should discuss risk with the patient. Aspects of the preoperative consultation
deemed most important are cardiac medication optimization (93%), cardiac risk stratification
(83%), addition of β-blockers (76%), and diabetes management (74%).
Conclusion: Surgeons perceive the most important roles for the internist as cardiac risk
stratification and medication management. Areas of controversy identified amongst the surgeons
included who should inform the patient of their operative risk, and whether the internist should
follow the patient daily postoperatively. Unclear expectations have the potential to impact on
patient safety and informed consent unless acknowledged and acted on by all. We recommend that
internists performing perioperative consults communicate directly with the consulting physician to
ensure that all parties are in accordance as to each others duties. We also recommend that the
teaching of perioperative consults emphasizes the interdisciplinary communication needed to
ensure that patient needs are not neglected when one specialty assumes the other will perform a
function.

Background decrease the morbidity and mortality that can arise from
There is abundant literature regarding the perceived role perioperative complications [1-5]. Internists perceive that
of internists in perioperative care. Guidelines for risk strat- preoperative consultations are requested to risk stratify
ification, optimization, and prophylaxis are proposed to and optimize patients for surgery thereby decreasing com-

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plication rates. In addition to clinical role models, our Likert scale indicated 1 (strongly disagree), 2 (disagree), 3
own literature teaches us how to be effective consultants (neither agree nor disagree), 4 (agree), and 5 (strongly
[6-11]. Surprisingly, there is little literature or guidance agree). Factors were listed to which they responded if they
from the surgeons who seek our services as to what they would consult medicine or anesthesia (or both). Lastly,
are looking for in an effective consultation. they were asked to write down comments they felt to be
important. The survey was developed after discussion
A multicenter survey of orthopedic surgeons, general sur- within our general internal medicine consultation group
geons, obstetricians/gynecologists, and general internists of specific patient concerns and noted gaps in care that
revealed significant differences in opinion between sur- were repeatedly observed. Exclusion criterion was sur-
geons and internists regarding issues such as limiting con- geons in our district who did not routinely request general
sultations to a specific question, writing orders on surgical internal medicine preoperative consults from our group
patients, and the concept of comanagement relationships (ophthalmology, and cardiovascular surgery). This is pri-
[12]. marily due to distribution of services in the city. Data was
tabulated and frequencies calculated on Excel 2003.
After discussion with referring services in our own center, Median values were calculated using SPSS version 15.0.
we realized there were different perceptions as to the role
of internists in the perioperative care of patients. This Results
raised concerns for gaps in care and physician satisfaction Forty-two of 71 (59%) surgeons responded. Respondents
as the consultee and consultant are not always aware of included orthopedic surgeons (9), general surgeons (7),
each others roles and intentions. Upon reviewing the lit- plastic surgeons (4), obstetrician/gynecologists (4), urolo-
erature, we discovered little to guide us in this area. With- gists (3), thoracic surgeons (2), vascular surgeons (2),
out discussing these issues with each other, the internist neurosurgeons (2), an otolaryngologist (1), and eight did
frequently proceeds with the consultation and periopera- not specify their area.
tive care based on his or her own assumptions of what is
wanted by the surgeon. This may result in suboptimal care The majority of survey questions and their results are out-
of patients. lined in Table 1. The majority of surgeons state they
request a preoperative consult for a difficult case (83%) or
The objective of this study was to survey the surgeons in a specific problem (81%). Sixty-nine percent disagree that
our city to understand why they ask for a preoperative it is requested for medico-legal reasons. While half agree
consultation and what they envision the internist's role to that it is to "clear a patient" for surgery, one-third disagree
be in perioperative care. with this statement. In the preoperative period, over 80%
believe the internist should discuss the risks with the
Methods patient, advise patients of medication changes, and con-
An anonymous survey was sent to all the surgeons in Sas- sult other specialties if indicated.
katoon, Saskatchewan, Canada who request general inter-
nal medicine consultations from our general internal Postoperatively, only 19% feel that the internist should
medicine group. Saskatoon is the referral center for almost follow the patient daily while 50% disagree with this. Fifty
300,000 people in the province and consists of a univer- percent feel the internist should see the patient postoper-
sity-based hospital and two community-based hospitals. atively only if called to review. Paradoxically, a majority
More than 30,000 surgeries are performed annually. The feel that the internist should adjust medications (eg. insu-
protocol was reviewed and approved by the University of lin, anti-hypertensive pills) postoperatively.
Saskatchewan Behavioral Research Ethics Board.
There were discrepant opinions as to whether the internist
The survey identified the surgeon's specialty followed by should inform the patient of risk, with the majority indi-
five statements outlining an internist's potential role in cating they strongly agreed with this statement but a sig-
perioperative care which the surgeons could (strongly) nificant minority (17%) indicating they disagreed or
agree or (strongly) disagree with using a five point Likert strongly disagreed with the internist informing the patient
scale. Surgeons were asked questions focusing on: (1) rea- of risk.
son for requesting a consult, (2) the amount of interaction
the internist should have with the patient, (3) the role of There was no consensus as to when a patient should ide-
the internist in the preoperative assessment, (4) the role of ally be seen preoperatively although most agree it should
the internist in the postoperative care, and (5) when a pre- be somewhere between three to seven days and two to
operative consultation should be scheduled. A five-point four weeks. The following time periods had responses for
Likert scale was also used to rank 18 aspects of periopera- agree or strongly agree: a) 24% for 24 hours preoperative
tive care that could potentially involve an internist. The

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Table 1: Responses of Surgeons Regarding Role of Internist in Perioperative Care. (Likert score: 1 – strongly disagree, 2 – disagree, 3 –
neither agree nor disagree, 4 – agree, 5 – strongly agree).

Median Likert Score (Strongly) Disagree (n = 42) (Strongly) Agree (n = 42)

Why do you ask for a preoperative consultation?

To "clear" a patient 3 14 19
Specific problem (example 4 7 34
diabetes, multiple medications).
Difficult case 5 4 35
Medico legal reasons 2 29 3
Ensure postoperative ward follow- 3 17 7
up

How much interaction should the internist have with the patient?

Written impression/ 2 28 12
recommendation (no discussion
with patient)
Inform patient of risk 4 7 33
Advise of medication changes/ 4 5 35
provide prescriptions.

as the ideal time frame; b) 45% for 3 to 7 days; c) 52% for specific concerns raised by the internist? These observa-
2 to 4 weeks and d) 10% for 8 weeks. tions prompted a literature review which provided limited
guidance to the clinical question of what surgeons expect
The presence of cardiovascular disease, risk factors for car- from internists. This absence of guidance formed the
diovascular disease and multiple medications prompted a impetus for the present observational study.
medicine consult rather than anesthesia (Figure 1). Obes-
ity, smoking, and type of surgery prompted a consultation Mollema et al retrospectively analyzed the types of
to anesthesia. Although obesity and smoking are risk fac- requests from surgeons at their site and the impact of the
tors for cardiovascular disease, medicine was not preferen- consultation [13]. They stated that 78% of the requests
tially consulted unless there was an established diagnosis. had clear questions although only 29% seemed to ask for
a specific recommendation about diagnosis or manage-
The aspects of an internist's perioperative care deemed to ment while half wanted an "evaluation". In our survey,
be most important are: optimization of cardiac meds although half agreed that they ask for a preoperative con-
(93%), cardiac risk stratification (83%), addition of β- sult to "clear a patient" for surgery, 81% also felt that they
blockers (76%), and management of diabetes (74%), res- were asking for a specific problem to be addressed. This
piratory risk stratification (62%), and preoperative medi- was a surprising response as anecdotal experience and the
cation assessment (62%). Aspects deemed least important literature finds that there is frequently a "general clear-
are: postoperative family discussions (74%), documenta- ance" request as opposed to a specific question stated on
tion of allergies (71%), postoperative fluid management the consultation request [8,9]. In Mollema's study per-
(67%), antibiotic prophylaxis (64%), and thromboem- formed in an academic center, only 12% of the consulta-
bolic prophylaxis (60%) (Table 2). tions resulted in a significant change in therapy or
outcome. In contrast to the study by Mollema our survey
Discussion directly asked the surgeons their opinions as to the reason
In contrast to the abundant literature surrounding inter- for consultation as opposed to a review of the written con-
nal medicine preoperative assessments, perioperative sultation. The two studies cannot be directly compared
management of patients, and the effectiveness of a medi- due to the different centers and methodology however in
cine consultation, we could find little literature outlining our study the surgeons perceive they are consulting for a
what surgeons expect from internists regarding periopera- specific problem but Mollema found that only 29% of
tive care. Our own anecdotal experience had raised con- written requests asked for specific recommendations
cerns that different specialties had different perspectives as about management and diagnosis of the patient.
to each others roles and duties leading at times to gaps in
care. For example, who would follow through with β- Katz et al. surveyed anesthetists and surgeons as to their
blocker prescriptions or who would inform the patient of perspectives as to the purposes and utility of cardiology

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that surgeons and internists are able to communicate their

" poor
protoplasm" mutual meanings behind this term.
activity level
There was strong agreement between our surgeons regard-
obesity
ing the important aspects of a consultation including car-
diac risk stratification, managing medications (including
multiple meds initiating β-blockers), and diabetes management. This is
medicine
in keeping with the literature aimed at internists regarding
smoker
anesthesia preoperative assessments.
both
CV risk factors either
As a consultant, we have often been taught that discus-
known CAD sions regarding the case should be with the referring phy-
sician and only with the patient by prior consent from the
surgery referring physician [15,16]. This has been a standard
0 5 10 15 20 25
teaching based on the assumption that the surgeon is in a
n=42
better position to indicate both the benefit of the proce-
Figure 1 Consultations
Characteristics
Anesthesia that Influenced
by Referring
Preoperative
Surgeons
Medicine versus dure and combine it with the internist's risk indicated to
Characteristics that Influenced Preoperative Medicine versus the surgeon. We often teach our residents that it is not the
Anesthesia Consultations by Referring Surgeons. (Character- internist's role to make judgments about whether or not
istic versus number of surgeons responding to the question). surgery is indicated or even to decide a patient is "too high
a risk" for surgery. Most internists do inform patients of
their perioperative risk [17] and we found that most sur-
consultations [14]. This study found substantial disagree- geons in our city agree with this. Still, a significant minor-
ment amongst the specialties on the importance and pur- ity of surgeons (12/42) felt that the internist should only
poses of a cardiology consult. As in our study they found write down their impression and recommendations and
that "clearing the patient for surgery" was not a unani- not have any discussion with the patient. Some comments
mously accepted reason for the consultation. This study, included "...risk of surgery is a discussion with patient/
like ours, found discrepant opinions as to the roles of each family by the surgeon, not the consultant unless discussed
specialist. They found that within and between specialties with the surgeon first" and "...discussing surgical risks
the answers to who is primarily responsible for ensuring may confuse/scare patient in whom this has been dis-
that the patient's medical condition is optimized before cussed already." We feel that this is a particularly concern-
surgery and who has the primary authority to declare that ing finding for patients because if both the surgeon and
an elective surgical case may proceed differ. This is similar internist assume that the other is informing the patient of
to our finding that there are discrepant opinions amongst particular findings/risks then the patient may never be
our surgeons as to the degree to which the internist should given essential information. While either perspective of
discuss risk directly with the patient and raises concern disclosure may be "right" it is critical that the consultant
that the patient may not be fully informed if each specialty and consultee ensure that their patients are given all infor-
"assumes" it is the other's role. mation they need to make a decision about their health
care choices.
As surgical techniques have improved over the years and
more elderly people are being operated on, the field of Although half of our surgeons feel that the internist
perioperative medicine is rapidly growing. The patients' should not routinely follow patients postoperatively,
outcomes will depend not only on the science and skill appropriate follow-up may improve compliance with rec-
behind the surgery and the preoperative risk assessment, ommendations and detect complications that may other-
but also must rely on the communication between the wise go undetected [14]. As was indicated from the
surgeon and internist. Without this communication, the responses in our survey, it is hoped that consultations are
internist frequently assumes that his/her opinion is requested for difficult or challenging cases or to deal with
wanted to provide "general clearance" of the patient when a specific question rather than for general "clearance" of
in fact the surgeon may have wanted a very specific ques- relatively healthy patients. We also found that surgeons
tion to be answered as our results indicate. We agree with want internists to manage multiple medications and initi-
the discussion by Katz that such a term is ambiguous and ate β-blockers if indicated. These scenarios mandate that
does little to clarify the reason for the consultation for at least a short period of follow-up ensue to ensure correct
either the internist [14]. As well it does little to ensure that medications are administered and to observe for postop-
the patient is well served by the consultation. Future peri- erative complications in higher risk patients, especially in
operative medicine teaching should focus on ensuring the first three to five days. Only eight of our respondents

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Table 2: Surgeons' Perceptions of Aspects of Medicine Consultation Deemed Most or Least Important. ((Likert score: 1 – strongly
disagree, 2 – disagree, 3 – neither agree nor disagree, 4 – agree, 5 – strongly agree).

Median Likert Score

Most Importance

Cardiac medication optimization 5

Cardiac risk stratification 5
β-blocker initiation 4
Respiratory risk stratification 4
Preoperative diabetes management 4
Postoperative diabetes management 4
Postoperative cardiorespiratory surveillance 4

Moderate Importance

Postoperative medication surveillance 3

Monitoring drug interactions 3
Family discussions re: risk 3
Management of alcohol withdrawal 3

Least importance

Venous thromboembolic prophylaxis 2

Antibiotic prophylaxis 2
Postoperative fluid assessments 2
Monitoring for alcohol withdrawal 2
Postoperative family discussions 1

felt that postoperative follow-up by the internist should opinions and needs from others. This has been observed
be routine. In a study of 146 medical consults Katz found in a study by Salerno et al where it was identified that
that few gave advice that truly impacted perioperative out- orthopedic surgeons differed significantly from general
come [18]. We postulate that improving the communica- surgeons and obstetrician/gynecologists in that they were
tion between specialties as to each others needs and roles more likely to prefer a comanagement relationship with
could improve on the benefit to the patient of periopera- internal medicine and wanted internists to broadly man-
tive consultations. age the patients as opposed to a narrow focus [12].
Although we are not able to indicate what different kinds
This study has limitations. First, this is a survey of sur- of surgeons may perceive as the role of internal medicine,
geons' attitudes and may not reflect what they are actually we feel that the main message of our study is that each
practicing as is evidenced by the fact that they believe they consulting group of general internists should determine
are asking a specific question most of the time (although their own surgeon's preferences and "assumptions" and
we perceive this is infrequently written). Surveys with not assume from the literature what individual surgeons
grading systems can be difficult to interpret. Although a perceive a consult is for. Lastly, our questionnaire was
space was provided for comments, the surgeons may not comprised of questions that we had for our surgeons. It
have been able to state their exact needs revolving around was not intended to be a validated survey that would
particular questions. We believe that follow-up discus- establish firm roles for either surgeons or internists in our
sions will be extremely important to identify surgeons' or other centers. Our goal was to have an initial, brief
attitudes and perceptions. Secondly, this survey may not introduction to their opinions so we could begin commu-
be generalizible to different types of surgical specialties nicating with each other to improve perioperative care
within our community or to other communities. Forty- and use the results of this initial survey as a basis for fur-
one percent of the surgeons surveyed did not respond thus ther research exploring the working relationship of gen-
limiting the ability to generalize the results. Also, as the eral internists and surgeons.
sample size in our district is small, we did not differentiate
the responses between university-based and community- Conclusion
based or between the various surgical specialties to main- Out study illustrates the importance of communication
tain anonymity. Some groups may have vastly different and collaboration between specialties to enhance care and

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Competing interests on the intended purposes and perceived utility of preopera-
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Authors' contributions atric services Edited by: Gross RJ, Caputo GM. Philadelphia PA: Lipin-
LPJ participated in the conception and design of the study, cott, Williams & Wilkins; 1998:8.
acquired the data, and drafted the manuscript. 17. Taher T, Khan NA, Devereaux PJ, Fisher BW, Ghali WA, McAlister
FA: Assessment and reporting of perioperative cardiac risk
by Canadian general internists: art or science? J Gen Intern Med
HAW performed the statistical analysis and drafted the 2002, 17(12):933-6.
18. Katz RI, Cimino L, Vitkun SA: Preoperative medication consul-
manuscript. tations: impact on perioperative management and surgical
outcome. Can J Anaesth 2005, 52(7):697-702.
SEC participated in the conception and design of the
study and drafted the manuscript. Pre-publication history
The pre-publication history for this paper can be accessed
All authors read and approved the final manuscript. here:

Acknowledgements http://www.biomedcentral.com/1471-2296/9/4/prepub
There was no external funding for this study.

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