Sometimes it’s worth second and third looks at the biggies. The cash machine known as the industry of “preop” clearance rests on little to no data. The CARP Trial
In 27 years of primary care I have only postponed 2 surgeries that I can recall. The preops for eye surgery, colonoscopies, simple ortho procedures, any preop testing in younger healthy asymptomatic patients, etc are completely unnecessary, but what do you do? Surgeons, surgery centers and anesthesia will not perform surgery without it. Its a liability shift more than assuring safety or best outcomes for the patient. I do the least amount of preop testing I can get by with. I do use time during the visit to review their postop plans, who will be with them when they go home and for how long (I have older, complex patients, many of whom live alone), their understanding of symptom and pain mgmt, realistic expectations for their recovery, who to call with questions. I find this more valuable to the patients
the "10 died in the 54 days it took to fix them vs 1 died in the 18 days they just went straight to surgery" detail is somehow both the most damning stat in this whole trial and the one that never makes it into the pre-op clearance pitch, waiting around to get "fixed" was measurably more dangerous than just skipping the fix entirely. also the "why even test for CAD if fixing it doesnt help outcomes" question feels like it should be the whole industry's problem and instead its buried in paragraph 15 of a substack post from 2026 about a trial from 2004, thats twenty two years of a null result losing to habit and billing codes. the AS/left main carve-out defense is fair but you already gutted it yourself, if a history and physical catches those, the entire stress-test-for-an-orthopedic-surgery pipeline is testing for problems doctors couldve just asked about
We were often consulted to provide “clearance” for cataract surgery , GI endoscopy, bariatric surgery on young individuals and almost any other procedure you can imagine. Though such generates RVUs and billing, I always felt part of our job was to assure the appropriate use of the resource, I.e., a specialist should not be consulted to do work that does not need to be done: costs to the system are astronomical and we all share in paying for it. I used to tell trainees, only partly in jest, “You could be having an MI and still get your cataract done”.
It's every physician, practitioner, and dentist trying to shift liability away. And docs that question it (much less an average person, egad!) are ridiculed and shamed for "not knowing the science".
I’m guessing without empirical evidence, ortho is driving this and dentists. Never a cardiovascular surgeon or even general surgery sends me these forms. Again just observation.
How many times have I had a patient waiting, lying in an ICU or Cards bed for days, awaiting clearance? ICU nurse here.
If a pt needs an EKG that takes me 10 minutes to perform and a couple minutes of the MD's time to read. Why is it a holdup? MRI? Sorry, not done on weekends. Echo, same. Pts wait. A procedure that should have been done tomorrow isn't done until next Wednesday.
A semantic thing… During the limited span of my non-EM career, I would push back at the “clear the patient for surgery” by pointing out that ‘clearance’ is not a thing! One can examine the patient in various ways for various things, and then offer the surgeon what amounts to a ‘risk assessment’. To the surgeon I would say: I cannot tell you the patient is ‘cleared for surgery’, all I can tell you is that based on my assessment, the surgery presents low, medium, or high risk based on certain current patient status elements. Then I rarely needed to say: given my assessment, you decide if your surgical plan is safe or not. Fortunately, I was not in the ‘clear the patient for surgery’ business very long…
I imagine CYA has a lot to do with it too. And this may be particularly relevant to the US medicolegal environment.
I like to tell people I can’t clear them to cross the street without being hit by a bus.
And in this case, I think there is a knowledge/education gap. I don’t think most docs realize revascularization of stable CAD does nothing to improve hard clinical outcomes. And that may include some cardiologists (who have no excuse).
I believe there is strong evidence that APPs (on average) order more tests and procedures. Once they are working for AI, I’m sure that trend will accelerate.
By the way, I also don't see how the APP "argument" is related to the pre-op clearance conversation? APPs aren't the ones asking for clearance...unless you mean a PA in a surgical practice who has been trained by his supervising doc to do so.
Maybe in primary care. Doesn't seem that way in EM (where I work as a PA), except when we know the attending doc will demand more tests, which is very commonly the case. I'd say the docs are more conservative/risk-averse than the APPs. And hardly anyone considers the downstream harms of overtesting--something I think a lot about thanks to Sensible Medicine and the like!
Don’t take what I said personally. There is a lot of data about APP hospitalists testing more than MD/DO hospitalists, I can’t but think that’s why there so many of them (less $$, bigger return per admission).
Fair enough. I could see that. Especially when they're in their first few years of practice.
One confounder from my personal observation is that the hospitalist APPs are more likely to be doing the overnight shift. So they're on their own, and they need to make sure there's enough data for the physician who shows up in the morning. Therefore they would naturally err on the side of ordering more rather than less in that scenario (b/c someone might complain if they don't order enough, but they'd be less likely to complain if they ordered too much).
A common thread here is that when APPs over-order, it's often due to either direct or indirect "pressure" from the physicians they work with. The example I just gave is an example of indirect pressure to over-order.
Thanks, John. I had to get a pre-op clearance recently before GI endoscopy. I have had stable mild LV stiffness with normal cardiac output, well-controlled hypertension, and no sign of CAD for years. Clearly, this "conservative" practice is a huge waste of medical resources and is likely NOT practiced in the UK.
I am retired now, but I distinctly remember one trial in ophthalmology where pre-op internal medicine consults resulted in WORSE outcomes for older adults needing surgery
As a now-retired PA in busy surgical practices, I was responsible for what must have been thousands of pre-op H&Ps. I can recall asking for preoperative clearances from cardiology only a handful of times, and then only for patients with significant unevaluated symptoms or a worrisome chronic condition that I knew would result in the cancellation of the procedure by anesthesia without a clearance. Over many years, I saw no evidence that PAs or NPs were inappropriately requesting preoperative clearances.
Yeah, it seemed strange that he (and at least one commenter) brought up APPs in this conversation. It doesn't seem like it has anything to do with it. Maybe just some subconscious biases that physicians like to bring up...
Requests for preop clearance by surgeons are mainly to prevent anesthesia delaying or cancelling the procedure the day of or day before when the anesthesia physician or CRNA reviews the chart. These requests are fairly common and quite frustrating for surgeons,patients, and the family.
Cancelled cases are anathema to surgeons, as that time cannot be recovered.
There is certainly an element of liability concern, as a law suit related to intraop or post op MI or cardiac complication will inevitably lead to plaintiff’s attorneys questioning the lack of pre op evaluation. Plaintiff’s attorneys can always find an expert who will say that is the standard of care without regard to the CARP trial and the jury presented an adverse event will believe that claim.
I know better but the ambulatory surgery center requires pre op clearance and I don’t want the patient to be caught in the middle. Very often they require lab tests and ekgs . In the US we spend over $18B on the testing component alone- not counting professional fees. Some hospitals are creating pre operative clearance testing centers.
When I went for my cataract operation clearance my family doctor told me that his criteria for clearing my was that I have a pulse.
Although fear of litigation has some relation to this it would all stop if insurance stopped paying for it
The ASC requires pre op clearance for a cataract procedure? I am not sure I am understanding what you mean.
I was owner and director of an ASC for 30 years, never had such a requirement for any procedure. High risk patients with general anesthesia required were done in a hospital environment.
Hard to justify for an ophthalmology procedure that takes 10 minutes or less.
I was amused when I would get consults from surgeons for clearing a patient with a neurologic disease for surgery. There certainly isn't any evidence base for doing that. Surgeons need to be trained to do their own evaluations of what the risk/benefit ratio is for the operations they do. I think they are just looking for cover in case of a bad result and a lawsuit.
Thank you! I've been interested in this topic since I was a resident over 30 years ago when I recognized the confusion amongst my colleagues and chose to do a Grand Rounds presentation on Perioperative Evaluation. Back then we used the Goldman Cardiac Risk Index which was very good. We've known the basics about assessing risk for over 50 years, yet the Surgeons or Anesthesiologists or whoever is in charge allow this excess to continue. Yes, I've had surgery cancelled because a patient scheduled for cataract removal needed "pre-op clearance" requiring an EKG that showed a RBBB or NSST/T changes.
In 27 years of primary care I have only postponed 2 surgeries that I can recall. The preops for eye surgery, colonoscopies, simple ortho procedures, any preop testing in younger healthy asymptomatic patients, etc are completely unnecessary, but what do you do? Surgeons, surgery centers and anesthesia will not perform surgery without it. Its a liability shift more than assuring safety or best outcomes for the patient. I do the least amount of preop testing I can get by with. I do use time during the visit to review their postop plans, who will be with them when they go home and for how long (I have older, complex patients, many of whom live alone), their understanding of symptom and pain mgmt, realistic expectations for their recovery, who to call with questions. I find this more valuable to the patients
the "10 died in the 54 days it took to fix them vs 1 died in the 18 days they just went straight to surgery" detail is somehow both the most damning stat in this whole trial and the one that never makes it into the pre-op clearance pitch, waiting around to get "fixed" was measurably more dangerous than just skipping the fix entirely. also the "why even test for CAD if fixing it doesnt help outcomes" question feels like it should be the whole industry's problem and instead its buried in paragraph 15 of a substack post from 2026 about a trial from 2004, thats twenty two years of a null result losing to habit and billing codes. the AS/left main carve-out defense is fair but you already gutted it yourself, if a history and physical catches those, the entire stress-test-for-an-orthopedic-surgery pipeline is testing for problems doctors couldve just asked about
We were often consulted to provide “clearance” for cataract surgery , GI endoscopy, bariatric surgery on young individuals and almost any other procedure you can imagine. Though such generates RVUs and billing, I always felt part of our job was to assure the appropriate use of the resource, I.e., a specialist should not be consulted to do work that does not need to be done: costs to the system are astronomical and we all share in paying for it. I used to tell trainees, only partly in jest, “You could be having an MI and still get your cataract done”.
It's every physician, practitioner, and dentist trying to shift liability away. And docs that question it (much less an average person, egad!) are ridiculed and shamed for "not knowing the science".
I’m guessing without empirical evidence, ortho is driving this and dentists. Never a cardiovascular surgeon or even general surgery sends me these forms. Again just observation.
How many times have I had a patient waiting, lying in an ICU or Cards bed for days, awaiting clearance? ICU nurse here.
If a pt needs an EKG that takes me 10 minutes to perform and a couple minutes of the MD's time to read. Why is it a holdup? MRI? Sorry, not done on weekends. Echo, same. Pts wait. A procedure that should have been done tomorrow isn't done until next Wednesday.
A semantic thing… During the limited span of my non-EM career, I would push back at the “clear the patient for surgery” by pointing out that ‘clearance’ is not a thing! One can examine the patient in various ways for various things, and then offer the surgeon what amounts to a ‘risk assessment’. To the surgeon I would say: I cannot tell you the patient is ‘cleared for surgery’, all I can tell you is that based on my assessment, the surgery presents low, medium, or high risk based on certain current patient status elements. Then I rarely needed to say: given my assessment, you decide if your surgical plan is safe or not. Fortunately, I was not in the ‘clear the patient for surgery’ business very long…
I imagine CYA has a lot to do with it too. And this may be particularly relevant to the US medicolegal environment.
I like to tell people I can’t clear them to cross the street without being hit by a bus.
And in this case, I think there is a knowledge/education gap. I don’t think most docs realize revascularization of stable CAD does nothing to improve hard clinical outcomes. And that may include some cardiologists (who have no excuse).
I believe there is strong evidence that APPs (on average) order more tests and procedures. Once they are working for AI, I’m sure that trend will accelerate.
By the way, I also don't see how the APP "argument" is related to the pre-op clearance conversation? APPs aren't the ones asking for clearance...unless you mean a PA in a surgical practice who has been trained by his supervising doc to do so.
Maybe in primary care. Doesn't seem that way in EM (where I work as a PA), except when we know the attending doc will demand more tests, which is very commonly the case. I'd say the docs are more conservative/risk-averse than the APPs. And hardly anyone considers the downstream harms of overtesting--something I think a lot about thanks to Sensible Medicine and the like!
Don’t take what I said personally. There is a lot of data about APP hospitalists testing more than MD/DO hospitalists, I can’t but think that’s why there so many of them (less $$, bigger return per admission).
Fair enough. I could see that. Especially when they're in their first few years of practice.
One confounder from my personal observation is that the hospitalist APPs are more likely to be doing the overnight shift. So they're on their own, and they need to make sure there's enough data for the physician who shows up in the morning. Therefore they would naturally err on the side of ordering more rather than less in that scenario (b/c someone might complain if they don't order enough, but they'd be less likely to complain if they ordered too much).
A common thread here is that when APPs over-order, it's often due to either direct or indirect "pressure" from the physicians they work with. The example I just gave is an example of indirect pressure to over-order.
Thanks, John. I had to get a pre-op clearance recently before GI endoscopy. I have had stable mild LV stiffness with normal cardiac output, well-controlled hypertension, and no sign of CAD for years. Clearly, this "conservative" practice is a huge waste of medical resources and is likely NOT practiced in the UK.
I am retired now, but I distinctly remember one trial in ophthalmology where pre-op internal medicine consults resulted in WORSE outcomes for older adults needing surgery
As a now-retired PA in busy surgical practices, I was responsible for what must have been thousands of pre-op H&Ps. I can recall asking for preoperative clearances from cardiology only a handful of times, and then only for patients with significant unevaluated symptoms or a worrisome chronic condition that I knew would result in the cancellation of the procedure by anesthesia without a clearance. Over many years, I saw no evidence that PAs or NPs were inappropriately requesting preoperative clearances.
Yeah, it seemed strange that he (and at least one commenter) brought up APPs in this conversation. It doesn't seem like it has anything to do with it. Maybe just some subconscious biases that physicians like to bring up...
Requests for preop clearance by surgeons are mainly to prevent anesthesia delaying or cancelling the procedure the day of or day before when the anesthesia physician or CRNA reviews the chart. These requests are fairly common and quite frustrating for surgeons,patients, and the family.
Cancelled cases are anathema to surgeons, as that time cannot be recovered.
There is certainly an element of liability concern, as a law suit related to intraop or post op MI or cardiac complication will inevitably lead to plaintiff’s attorneys questioning the lack of pre op evaluation. Plaintiff’s attorneys can always find an expert who will say that is the standard of care without regard to the CARP trial and the jury presented an adverse event will believe that claim.
I know better but the ambulatory surgery center requires pre op clearance and I don’t want the patient to be caught in the middle. Very often they require lab tests and ekgs . In the US we spend over $18B on the testing component alone- not counting professional fees. Some hospitals are creating pre operative clearance testing centers.
When I went for my cataract operation clearance my family doctor told me that his criteria for clearing my was that I have a pulse.
Although fear of litigation has some relation to this it would all stop if insurance stopped paying for it
The ASC requires pre op clearance for a cataract procedure? I am not sure I am understanding what you mean.
I was owner and director of an ASC for 30 years, never had such a requirement for any procedure. High risk patients with general anesthesia required were done in a hospital environment.
Hard to justify for an ophthalmology procedure that takes 10 minutes or less.
That was my experience practicing both in Northern Ca and NJ. In addition to everything else it clogs up our appointment schedules
I was amused when I would get consults from surgeons for clearing a patient with a neurologic disease for surgery. There certainly isn't any evidence base for doing that. Surgeons need to be trained to do their own evaluations of what the risk/benefit ratio is for the operations they do. I think they are just looking for cover in case of a bad result and a lawsuit.
Beautiful
Thank you! I've been interested in this topic since I was a resident over 30 years ago when I recognized the confusion amongst my colleagues and chose to do a Grand Rounds presentation on Perioperative Evaluation. Back then we used the Goldman Cardiac Risk Index which was very good. We've known the basics about assessing risk for over 50 years, yet the Surgeons or Anesthesiologists or whoever is in charge allow this excess to continue. Yes, I've had surgery cancelled because a patient scheduled for cataract removal needed "pre-op clearance" requiring an EKG that showed a RBBB or NSST/T changes.