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Comment & Response
June 2014

Response to "Mandatory Anesthesia”

Author Affiliations
  • 1Department of Anesthesia, Baystate Medical Center, Springfield, Massachusetts
JAMA Intern Med. 2014;174(6):1010-1011. doi:10.1001/jamainternmed.2014.1416

To the Editor I read the opinion piece titled “Mandatory Anesthesia” with great interest.1 It raises some excellent questions regarding anesthesiology, safety, and health care expenditures.

Let's begin with “medical clearance” for operative interventions. In academic environments, all elective patients are screened by an anesthesia provider. This involves a history and physical examination, possible laboratory work, and additional studies dictated by the case and patient comorbidities.2 Institutional guidelines exist in terms of a perioperative workup. These guidelines are loose, not necessarily evidence based, and ever evolving. We have made some progress since Dr Goldman's criteria.3 In private practice, unless the anesthesia department is queried directly, it is the surgeon's obligation to provide a necessary workup prior to surgery in an effort to avoid day-of-surgery delay or cancellation. These decisions are made without the direct consultation of the anesthesia department. The behavior for many surgeons is to order “everything under the sun” in order to minimize day of surgery delays. There is no incentive for the surgical community to behave otherwise. As for the preoperative workup for the author’s brother,1 I agree that the tests ordered were superfluous, expensive, and most likely mandated by the surgeon or mistaken institutional protocols. The most I mandate for a topical cataract, in a medically stable patient, is an appropriate fasting state.

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