Table 4.

Themes related to drivers of current practice, potential improvements and barriers to change

Theme	Number of interviews supporting theme, representative quote	Number of interviews opposing theme, representative quote
Hospital and/or anesthesiology requirements (including informal or perceived requirements) are a major driver of surgeons’ use of preoperative services.	14 interviews “For major surgery, everybody needs to get a set of pre-operative tests, and the standards are set mostly by the hospital where the surgery is going to take place. Some of these hospitals send us a grid and on one side there are patient’s characteristics like age, whether they are a smoker, whether they have certain medical conditions. On the other end, based on the response to the first set of questions, it tells us whether we should get an electrocardiogram, a chest X-ray, some blood work, etc. What we do most of the time, because it’s always better to have more than have your surgeries get delayed because you didn’t get enough, we go ahead and get more extensive blood work. Let’s say they request basic chemistry, we may go ahead and get some liver function tests as well.” -Private practice colorectal surgeon	2 interviews “I get coags on everybody and I think that some people push back and say you don’t need to do that unless somebody has some history of a bleeding problem or something along those lines. [Even if anesthesia didn’t require them], I would still get them.” -Academic orthopedic surgeon
Surgeons receive minimal formal training on performing preoperative medical evaluations.	13 interviews You know, my residency didn’t really—we do kind of general surgery time and stuff like that, but certainly in medical school, I never really learned “here’s how to properly preop the patient.” We sort of encountered it a lot as you would, for example, consult medicine to see if you can fix some old lady’s hip. You’d sort of learn indirectly by seeing how they would clear them, but I guess I never really learned formally the right ways to do it. -Private practice orthopedic surgeon	1 interview I did [get specific training about what to order on who and why] for disease processes that could produce intraoperative problems. So hyperthyroidism, pheochromocytoma, those sorts of things. Did I get training about more subtle things? Like, for example, this person is taking Plavix, here are the things you need to do about those patients. Not really. -Academic endocrine surgeon
Surgeons’ preoperative medical evaluation practices are similar to their colleagues’ practices.	14 interviews “My senior partners had been doing this for 30 years, and so I kind of just picked up the flow of how the office works and how they do [the preoperative medical evaluation].” -Private practice breast surgeon	4 interviews “I think my colleague probably does fewer testings, like in terms of cardiac clearance. I think that he may, for example, instead of having a cardiology work them up, he says, I’ll just go ahead and order an ECHO or a stress test. And if those look fine then he clears them.” -Private practice thoracic surgeon
The preoperative medical evaluation reduces surgeons’ malpractice risk.	12 interviews “I guess it probably would give you a little defense if patient develop post-op medical issue. Then it probably will be a help defensively to say hey, I got the medical opinion on that. There’s no question that’s part of the deal when you get a medical clearance.” -Private practice vascular surgeon	2 interviews “I guess it could go both ways in the sense that I mean in theory [the preoperative medical evaluation] should lower [the malpractice risk], but in reality if you do not read the note, it may increase it.” -Private practice colorectal surgeon
Surgeons welcome standardization of preoperative medical evaluation protocols.	6 interviews “I think there were sort of national or at least sort of acceptable agreed upon standards between institutions, I think that would just be a lot easier because then theoretically it would be more interchangeable. Like if we just agreed that, you know, this is the definitive article and here’s this grid. Wherever you fall on this grid, this is how we’ve decided as a medical community that people are cleared for surgery. Then you can go anywhere and do it and you know what people are going to get, and it kind of takes the guesswork out.” -Private practice orthopedic surgeon	2 interviews “It would be nicer if things weren’t mandatory, because in some cases--especially in the hospital--if a patient is coming in two months later, and their pre-op was done 75 days ahead, and you know that there hasn’t been a whole lot of change in the interim, it would be nice if we could kind of use our judgment. But, they don’t allow room for that, because I guess they don’t want to trust people’s judgment.” -Private practice plastic surgeon
There is inadequate evidence regarding the benefits of preoperative medical evaluation.	3 interviews I definitely don’t know if it is absolutely necessary to preop my young 20-year olds. I mean is there a possibility that something could pop up during some of their routine blood work or something? Of course. But you know that from a cost analysis standpoint I don’t know if it is really needed. More studies that need to look into that. -Private practice orthopedic surgeon	0 interviews