A 41-year-old man who is 5 ft 7 in tall and weighs 373 lb comes into the clinic once or twice a year for BP monitoring and obesity counseling. Six months after his most recent visit, he told me that he had suffered a bout of kidney stones and had consulted a urologist for treatment. The urologist had placed a stent in his left kidney and was now unable to remove it. Since his appointment with me and after more than a year with the stent in place, he has seen another urologist to have the stent removed. The office manager called me to get “clearance” for this procedure. I refused because I was unaware of the patient’s visit to the first urologist and unfamiliar with what went wrong. What are my legal and ethical obligations? Are decisions to clear patients for surgery within the scope of practice for primary-care nurse practitioners or physician assistants?
—Debra C. Allen, ANP/GNP, MSN, Reidsville, N.C.

Clearance for surgery is common in hospital practice and usually implies that the patient is well enough to tolerate general anesthesia. In this case, the patient has significant medical problems (i.e., obesity and hypertension). The prudent course would be to recommend physician review of the case before surgery and have the internist follow the patient while he is in the hospital. As for clearing a patient in good general health for surgery, it is appropriate from a risk-management standpoint to describe the patient’s overall health and conclude, “This patient’s good respiratory and cardiovascular status indicates a low risk with general anesthesia.” However, patients with chronic problems probably require assessment from an internist or cardiologist.
—David S. Starr, MD, JD