I would like to thank and congratulate Wijeysundera et al1 for a superbly performed and important study.1 I would also like to solicit their thoughts on an additional interpretation of their findings. Perhaps consultation was associated with both a decreased use of epidural anesthesia and a lower rate of outpatient postoperative thromboprophylaxis because perioperative caregivers were sometimes falsely reassured that patients seen in consultation had been “cleared” and were therefore at lower risk for complication. This dovetails with the possibility that surgeons who felt comfortable evaluating and managing medical comorbidities may have been less likely to obtain preoperative medical consultation and that these surgeons' patients received superior perioperative care from the surgical team. What has the most potential to affect outcomes is the day-to-day perioperative care of the patient. Even when a consultant provides appropriate recommendations based on an assessment of the entire patient, these recommendations may not be effectively performed in the perioperative period. As expressed by Chassin et al,2(p686) “The beneficial effect of processes . . . far upstream from outcomes will be nullified if important processes closer to the outcome are not performed effectively.” For example, upstream processes may be nullified by poor communication.3 It has been demonstrated that consultants' recommendations are often not followed.4 Furthermore, there is evidence that when an internist actively participates in the comanagement of surgical patients, outcomes do improve.5 Perhaps what is needed to improve surgical outcomes in patients with medical comorbidities is not preoperative medical consultation but perioperative comanagement.
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