Pre-Ops in Private Practice

There are many differences between academics and private practice. For someone like me, who spent the last five years in an academic medical center, the change can be a little jarring. Some of it has to do with money; if something doesn't justify its cost, then in private practice, it's eliminated. In academics, research, teaching, and the latest evidence are emphasized. In private practice, safety, conservative management, and efficiency are king. I don't think either perspective is necessarily better or worse; it's simply a difference in mission.

Even before a patient arrives for surgery, the process is quite different. In residency, patients go to a "pre-anesthesia clinic." They are seen by a resident or a nurse practitioner who reviews their medical history, checks their medications, and ensures that they are appropriate for elective surgery. An anesthesiologist determines what laboratory and other tests (like EKG or chest X-ray) are necessary prior to surgery. The patient receives information on how to prepare for their operation, gets an overview of what to expect, and asks questions. However, preoperative clinics end up costing a hospital or anesthesia group; pretty much everything we do is not reimbursed by insurers. There may be some cost savings if the pre-op clinic decreases last-minute cancellations or reduces complications. But overall, it's a thankless endeavor. It also requires a lot of coordination; we try to schedule appointments right before or after a patient meets their surgeon. But if one clinic is delayed, it can greatly impact the other. I've had many patients coming from out of town complain because the process of getting ready for surgery takes all day.

This kind of thing is not practical in private practice. Our surgeons have offices in many locations, and it would be impractical to have all our patients go to a separate anesthesia clinic after their surgical appointment. We don't have the staffing to see every pre-operative patient; in residency, that clinic had over five nurse practitioners a day along with a resident and an attending. Furthermore, we don't necessarily like the idea that the person seeing the patient pre-operatively is different than the physician caring for them on the day of surgery. To make things more efficient, the anesthesiologist caring for a patient gives her a phone call the night before surgery. It can make the end of my day quite long, but it allows me to ask for whatever information I think is necessary and gives me the opportunity to introduce myself to a patient. I think it minimizes inconvenience to the patient. However, there are limitations. I don't do a physical exam until the day of surgery. If I identify something that needs to be optimized, I don't have much time or opportunity to do so. I don't control what tests are ordered. Nevertheless, it ends up being the most cost-effective way to ensure our patients get a reasonable pre-operative evaluation.