Blog | Monday, January 31, 2011

Don't treat pre-op exams like pop quizes

What's one of the biggest culprits for the rise of unnecessary medical testing? Preoperative evaluation.

Before most patients undergo surgery or an invasive procedure, they are normally sent to their primary care physicians for a "preoperative evaluation." This is a visit to determine if they are medically stable enough to undergo the operation.

Tests like bloodwork, an EKG, or a chest X-ray are frequently ordered. For those with suspicion of coronary artery disease, a stress test is sometimes considered, based on the patient's symptoms.

According to a recent study, however, many of these tests may be unwarranted. Not only do they waste money, they also can potentiate further, more invasive, studies that stem from incidentilomas.

Published in Obstetrics & Gynecology, researchers: "reviewed medical records for women who underwent gynecologic surgery at their center between 2005 and 2007. They found that 95% of the 1,402 patients received all the recommended testing, but 90% had at least one test that was not necessary based on guidelines from the National Institute of Clinical Excellence (NICE).

"None of the 749 urine tests, the 407 liver function tests, or the 1,046 tests of blood clotting factors were appropriate, while 99% of the 427 chest X-rays ordered were not appropriate. Only 36% of the electrocardiograms and 29% of complete blood counts were in accordance with "evidence-based" guidelines."

There are several reasons. Of course, malpractice worry is at the back of most doctors' minds. As the chief author puts it, "'Number one, certainly, a lot of this is medicolegal,' meaning, basically, doctors don't want to get sued for not having a test done."

Also, the entire medical team needs to be on the same page. Meaning, the preoperative guidelines for the primary care doctor, surgeon, and anesthesiologist has to be the same.

If I don't feel like a certain preoperative test is necessary, for instance, it shouldn't be ordered by a consultant. This is difficult in most practices, where the preoperative doctor, surgeon and anesthesiologist operate under separate auspices.

Having everyone under the same roof, such as in a large, integrative practice, can help in consolidating the recommendations and, perhaps, reduce $3 billion wasted on unnecessary preoperative tests.

Kevin Pho is founder and editor of, also on Facebook, Twitter, and LinkedIn.

This post by ACP Member Kevin Pho, MD, originally appeared on MedPage Today's, social media's leading physician voice. Voted best medical blog in 2008, and with over 40,000 subscribers and 28,000 Twitter followers, is the Web's definitive site for influential health commentary.