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INTRODUCTION

Preoperative medical consultation and perioperative management of the surgical patient are important roles in the clinical practice of internists, hospitalists, and subspecialists. The role of the hospitalist has expanded to include comanagement for orthopedic, neurosurgical, vascular, and other surgical patients, and even the role of the anesthesiologist has evolved, focusing on perioperative medicine outside the operating room setting as well. This chapter will discuss principles of medical consultation and the role of the perioperative medical consultant. Specifics regarding risk assessment and management will be discussed in subsequent chapters.

ROLE OF THE PERIOPERATIVE MEDICAL CONSULTANT

The role of the perioperative medical consultant can be described as having three main goals:

  1. Preoperative risk stratification – to define and evaluate the patient's current medical conditions, uncover previously unrecognized problems, and estimate the patient's surgical risk

  2. Medical optimization – to recommend risk reduction strategies, perioperative medication management, and any additional testing if indicated

  3. Postoperative follow-up – to re evaluate medical problems, ensure compliance with recommendations and medical therapy, provide advice, and anticipate, recognize, and treat any postoperative medical complications

GENERAL PRINCIPLES OF MEDICAL CONSULTATION

In 1983 Goldman and colleagues1 published their “Ten Commandments” for effective consultation which were modified in 2007 by Salerno and colleagues2 (Table 1-1). These basic principles included: 1) Determine the question. 2) Establish urgency. 3) Look for yourself. 4) Be as brief as appropriate. 5) Be specific and concise. 6) Provide contingency plans. 7) Honor thy turf. 8) Teach with tact. 9) Talk is cheap and effective. 10) Follow-up. The basic meaning of these concepts is noted in Table 1-1, and they will be highlighted throughout this discussion.

TABLE 1-1Original and Modified Ten Commandments for Effective Consultations

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