The one sure fact about the news of Dr. Dondra West’s death, even from a distance, is the tragic loss to the world of a wonderful person. I extend my heartfelt condolences to those who knew and loved her. While the media speculates about the circumstances of her death, I’d rather, instead, focus on a major health issue that this great lady’s sad passing brings into the public’s awareness–the role of, and need for, a “medical clearance.” CNN reported about Beverly Hills cosmetic surgeon Andre Aboolian, “He simply said that in order for him to be comfortable, he felt it necessary to have a medical clearance before he’d touch her.” So he sent the patient to an internist. Which raises the following obvious questions:
What the heck is a medical clearance? Isn’t it just a second opinion (and wouldn’t a second surgeon be better for that)? Why would a specialist send a patient to a general doctor–doesn’t the specialist, by definition, know more, especially about what’s likely to go wrong with an operation? Why won’t my insurance company pay for a medical clearance? Who decides if you need a medical clearance? Why (and when) should I demand one?
Here’s the Doc Gurley Medical Clearance Low-Down:
1) Surgeons have a conflict of interest when it comes to deciding who is “safe” for surgery. Surgeons get paid to operate and, frankly, if a surgeon doesn’t love operating, she shouldn’t be a surgeon. In general, if you ask any surgeon about any problem (gallstones, hangnails, baldness, global warming) the answer is an operation. Therefore, a long-standing medical tradition exists of surgeons sending their prospective patients to an internist (or other, similarly qualified generalist) to assess the patient for the possible risks of surgery. This relationship–surgeon wants to operate, internist checks under the hood to see if there are potential problems beforehand–is called a medical clearance. The internist acts independently, and can be held accountable if he/she clears a patient who then develops predictable problems with the surgery. It’s also the internist’s job to get the patient (medically) in tip-top shape before elective surgery. Therefore, the internist can cancel surgery, even if the patient and surgeon are miffed about it. If this happens, the surgery is usually only cancelled until further tests are done, or until the medical problem is treated (by the internist). Here’s a fictional example. Patient Patty wants to get breast implants. The plastic surgeon sends her for medical clearance. Internist Ira discovers Patty has a strong family history of pancreatic cancer and melanoma–but only on her father’s side. Internist Ira knows enough about the genetic risks of breast cancer to put an entire cocktail party to sleep, knowledge which includes the weird fact that a family history of melanoma and pancreatic cancer can be linked to an increased risk of breast cancer. Patty is 39, and hasn’t had a mammogram yet. Internist Ira does a breast exam (everything normal) and then orders a mammogram, which shows a suspicious spot. The internist cancels breast implant surgery and refuses to medically clear Patient Patty until the spot is diagnosed.
2) A second opinion, in contrast, is another surgeon’s assessment of whether or not you need this particular surgery in the first place. You’ve been told you need a hernia repair. But you’ve heard (see #1 above) that surgeons love to operate. Besides, you’re not too keen on anyone getting close to your privates with a scalpel. So you decide to ask another surgeon whether or not he also thinks you ought to get the hernia repaired. After the second surgeon waits 37 minutes for you to maneuver, through the doorway, the wheelbarrow containing your scrotum, he says, yep, you need the hernia fixed. That’s a second opinion. If the second surgeon then wonders what else might be wrong (medically) with someone who waited so long to get a hernia fixed, he’d send you for a medical clearance to find out.
3) Surgeons know surgery. They are uber-specialized. [Actual example: you can specialize to where the only surgery you do is eye surgery, and then you can specialize in eye surgery only in the part of the eye between the pupil and the outside of the cornea–a tiny area called the anterior chamber. In children. Which makes you a pediatric anterior chamber ophthalmologist with a sub-specialty of operations on the mesh that hold the lens in place. Is that specialized enough for you?] All this means that surgeons (in general) no longer know the broad knowledge of diabetes management, blood pressure control, cardiac risks, cancer screening, infection control, etc. etc. In general, the more specialized the surgeon, the more narrow their knowledge. A generalist, in this circumstance, actually knows much more than the specialist. For example, high blood pressure can increase the risk of heart attacks during surgery. That blood pressure better be under control before elective surgery–which is the bread and butter job of an internist. And, predictably, there are internists who specialize in medical clearances. A large body of medical literature exists about the risks of certain surgeries, and the patients who have those operations–so much so that certain expensive tests are now routine pre-surgery evaluations.
3) So far, we’ve talked about what’s best for the patient (and surgeon), right? Well, what about who pays for all this? If you’re an insurance company, how excited are you going to be about paying for one doctor to send your client to another doctor–just to find things that generally have NO SYMPTOMS. Not thrilled, right? The problem is even worse if the proposed surgery would never be paid for by the insurance company (like plastic surgery, or LASIK). How come the insurance company has to pay for you to get a medical clearance for surgery they don’t cover? It’s often not just a second doctor visit–what about all the tests that might be needed? As you can imagine, no matter how important or useful medical clearance might be–insurance companies tend to squawk about it. Medical clearance is clearly indicated for many operations, with the general rules being–the more medical problems you have, the more you need a medical clearance, and, the more invasive the surgery, the more you need a medical clearance, even if you don’t have known medical problems. And what if it’s an emergency operation? Well, everyone does the best they can under the circumstances. Medical clearance, optimally, is to prevent problems that are, possibly, preventable.
4) So who decides if you need a medical clearance? In general, the surgeon. She decides if you have risks, she decides what her tolerance for those risks are, she even may be the only one who knows that you want to have an operation. In this age of Extreme Makeovers, it’s easy to forget that you don’t “go to sleep” when you have surgery–it’s more like being put into a near-death coma. A wise surgeon wants patients who will do well, and a wise surgeon wants patients in the best shape possible before surgery.
5) When should you ask for (or demand) a medical clearance? A surgeon who wants a medical clearance is worried about something–or recognizes his own limitations when it comes to pre-op screening for diseases and complications. That’s something to respect. Anytime a surgeon thinks you need a medical clearance–go for it. It’s hard if you’re hurting every day and you need your knees replaced and you’ve waited three months for pre-authorization and an open OR time and then some doofus general doctor says you can’t have the surgery because your blood pressure’s a little high. One way to console yourself is to imagine that the whole situation is like getting delayed at the gate because the airline wants to check out a part in the engine that’s making a funny sound (maybe). When you look at the big picture, you really do want to wait and be sure. If you’re paying out of pocket for the surgery, consider the med clearance process part of the total cost. If you can’t afford both the surgery and the med clearance, wait and save some more–some things are best NOT done on the cheap. Which raises another scenario for when you should ask for a medical clearance: with the rash of people going overseas for less expensive operations, if you’re one of them (or considering that option) be sure your regular doctor knows, and make sure you get a medical clearance beforehand if you have ANY health problems at all. Medical clearance is generally not a part of one-time surgery in another country.
Be well, and grieve the loss of a great woman.
Image courtesy of antiqueclipart.com