Medical Clearance

Susan L. Marr, MSA, CPHRM, Patient Safety/Risk Management Account Executive, The Doctors Company.

As the first medical malpractice insurer to establish a patient safety department, The Doctors Company remains the leader in developing innovative tools that can help you reduce risk and keep your patients safe.

“Medical clearance” is a term used in several situations. For example, when a fitness trainer requires a client to have medical clearance from a primary care physician before beginning an exercise program; when a student athlete needs clearance from his or her physician to participate in sports; and, typically, when a surgeon requests medical clearance before performing surgery on a patient. We address the latter situation here.

Develop criteria for determining which patients need medical clearance.

Determining which patients need clearance begins with assessing the type of surgery and its associated risks and the health of the patient. Healthy patients with no underlying conditions who are undergoing fairly low-risk procedures don’t routinely need medical clearance. Cardiac risk is the chief concern of most surgeons, and it is the number one reason to request a medical clearance.

Provide appropriate information to the assessing physician.

Ideally, medical clearance involves an exchange of information between the surgeon and the assessing physician. The surgeon is encouraged to provide information about the type of surgery, how long it will take, what kind of anesthesia is anticipated, how long the patient will be immobile, what is involved in rehabilitation, and what the recovery period looks like. The assessing physician takes that information into consideration, along with exam results and knowledge of the patient, to determine if the patient is at increased risk and what might be done to mitigate risks preoperatively, intraoperatively, and postoperatively.

Ensure clear communication with the assessing physician, and develop a plan to mitigate risks.

Ideally, the surgeon and the assessing physician work together to determine the steps to take in order to mitigate risk to the patient. They should agree, for example, about which medications to stop preoperatively and which to continue. Problems with anticoagulants are often an issue in surgical claims. If the patient is taking anticoagulants, the surgeon and the physician should agree on the best approach for the specific patient, given that individual’s risk factors. They may discuss changes in medical management that should be made to decrease risk. For example, if they believe the patient is at risk from a respiratory perspective, the focus may be on early mobilization, incentive spirometry, and respiratory treatment.

Medical clearance is a misnomer because it implies that the patient is cleared and there are no risks. As we all know, no patient is free of risk when undergoing a procedure. The goals of the assessment are to determine the level of risk and to identify opportunities to mitigate risk—with the surgeon and the assessing physician working in concert. The decision about whether to proceed with the operation belongs to the surgeon and the patient.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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