Anesthesia is often viewed as a support service in the operating room, but leaders say the specialty plays a critical role in everything from patient optimization and safety to staffing, scheduling and throughput. Becker’s spoke with anesthesia leaders across the country about the misconceptions they encounter most often and what they wish surgeons better understood about how anesthesia works at their facilities.
Editor’s note: Responses have been lightly edited for clarity and length.
Question: What is one thing you wish surgeons understood about how anesthesia works at your facility?
Rita Agarwal, MD. Clinical Professor of Anesthesiology at Stanford (Calif.) University: I work in pediatric anesthesiology, where we are often asked to provide anesthesia for patients and procedures that could be done with minimal or no sedation in older patients or adults. Many of these patients are sick. I wish surgeons and proceduralists understood that while the surgery or procedure may be “minor,” the anesthesia is not. Medically complex patients require careful preparation and safety precautions before anesthesia can proceed, and what may seem like a quick case can involve significant anesthetic risk, planning and coordination behind the scenes.
David Albert, MD. Director of Anesthesia Services at Midtown Endoscopy Center (New York City): Over the past 40 years in practice, our profession has gotten exponentially safer. Now, it is the norm rather than the exception that patients are older and sicker; at the same time we have significantly reduced morbidity and mortality. Because of our success, surgeons take our efforts for granted and the risks are minimal for even the sickest of the sick. In this regard, we have become our own worst enemy. Because of our safety record, we are expected to always have a complication free experience. This is unrealistic but a difficult lesson to teach to our surgical colleagues.
Mo Azam MD. Head of Innovation at US Anesthesia Partners (Dallas): Surgeons and anesthesiologists have shared goals for patient care, but also similar challenges in our practices. We both want to provide the highest quality care for patients. We also have to be able to do that while being efficient and productive. Surgeons don’t want down time and neither do anesthesia professionals. Surgeons and anesthesiologists work most effectively when they function as a coordinated team, both in providing patient care and in efficient OR utilization. That’s the best way to ensure full coverage of cases, and better access to care.
Andy Briggs, CRNA. CRNA Clinical Education Coordinator at UCHealth (Colorado Springs, Colo.): One concept I wish our surgical colleagues understood at our facility is the dynamics of the care team model under medical direction and how much it limits the scope of CRNA practice. CRNA autonomy, in opt-out states, can be a helpful tool in allocating providers while surgical volumes are high and staffing numbers are dramatically low related to call requirements and off-shift obligations. While I’m not fond of the militant stance on independent CRNA practice in all models and cultures, I do indeed support opening the conversation in certain circumstances.
Zohn Centimole, PhD, CRNA. Assistant Director of the Nurse Anesthesia Track at the University of Louisville (Ky.): I work at an academic medical center. We train nurse anesthesia residents here along with physician anesthesia residents. From entering the OR, through induction and incision, this time is the most pressure packed portion of a typical anesthetic. We know surgeons want to start ASAP. However, their being patient and graceful as the nursing assistant-resident performs procedures can make or break their success, and their day. Surgeons’ patience and support may be the factor that influences their taking a job at your facility. That ultimately will help surgeons with block time and their patients’ outcomes.
Melissa Croad, MSNA, CRNA, APRN. President of the Massachusetts Association of Nurse Anesthesiology (North Dartmouth): One of the major misconceptions surgeons have about anesthesia, and CRNAs specifically, is that they are liable for their actions. This has been proven repeatedly, as early as 1917. Despite this, the belief is commonplace and used as an excuse to impose physician-anesthesiologist supervision on CRNAs who do not actually require it.
This is truly as simple as saying no to physicians, surgeons or anesthesiologists, being liable for the actions or omissions of CRNAs, but it is also relatively complicated to understand.
Katy Dean, CRNA. Chief Nurse Anesthetist at TKMAnesthesia (Newport News, Va.): One thing I wish surgeons better understood is how much scheduling affects an ASC’s financial health and operational efficiency. While anesthesia is often viewed as a variable expense, staffing costs remain even when cases are canceled at the last minute, creating lost revenue and higher overhead. Providing advance notice of major schedule changes, maximizing block utilization and consolidating cases into fully utilized operating days helps avoid underutilized ORs, anesthesia coverage inefficiencies and unnecessary staffing costs. Ultimately, these practices allow anesthesia, nursing and facility resources to be used more effectively, improving both operational and financial performance for the ASC.
Jason Forro, CRNA. Director of Anesthesia and Ambulatory Services at Trinity Health Ann Arbor and Livingston (Mich.): One thing I wish surgeons better understood is that anesthesia functions as a system, not just a service supporting surgeons, but also non- operative proceduralists and care delivery across the perioperative environment. Delivering safe and efficient care requires balancing staffing, patient complexity and workflow, and those resources are not unlimited. Finally, operating room efficiency should be firmly aligned with anesthesia capacity and efficiency, not viewed independently.
Megan Friedman, DO. Chair and Medical Director at Pacific Coast Anesthesia Consultants (Los Angeles): One thing I wish surgeons understood is that anesthesia is fundamentally a coverage model, not a per-case service. We are expected to staff operating rooms, non-OR procedural areas, labor and delivery, emergencies and add-on cases regardless of whether every location is busy all day. Because of that, decisions that may seem small, such as adding a room, extending block time, or making last-minute schedule changes can have significant staffing and financial implications across the perioperative system.
The most successful facilities are those where surgeons, anesthesia leadership and administration plan together. Anesthesia has visibility across the entire perioperative enterprise and can help balance access, efficiency, cost and patient safety.
Rick Middleton, CRNA, MSN. Director of Anesthesia Services at UNC Health Wayne (Goldsboro, N.C.): I wish surgeons understood the amount of time anesthesia teams now spend evaluating and optimizing patients. An aging population, rising rates of comorbidities and morbid obesity and the growing number of complex medications all affect the pre-, peri- and postoperative anesthesia plan. In the past, when patients were predominantly ASA 1 and 2, with fewer ASA 3 and 4 patients, planning and care were often much simpler. Today, the prevalence of higher-acuity patients requires more time for optimization and day-of-surgery preparation, including lines, regional blocks and heart rate, blood pressure and glucose management. As a result, anesthesia care is more complex, and the rapid turnover of cases that was once common is less likely to occur.
Sean Overton, MD. Associate Professor of Anesthesia and Critical Care at the University of Utah School of Medicine (Salt Lake City): Anesthesia is a finite, pre-committed resource. The moment a provider is assigned to a room, they are fully deployed. There is no pause when a case is delayed or a room sits idle.
Every minute of anesthesia time represents a real cost and a real opportunity, which means we need to be thoughtful stewards of that time together. Accurate case booking, fully utilized blocks and timely communication about planned unused time all protect access for patients and surgeons across the system.
Our capacity to say yes to the next case depends on how well we manage the current one.
When anesthesia wins, surgery wins and the system wins. When the OR runs efficiently, everyone’s patients benefit. That is a team outcome, and it starts with a shared understanding of the resource we are all working with.
Amit Prabhakar, MD. Chief of Anesthesiology at Emory University Hospital Midtown (Atlanta): If there is one thing I wish more surgeons understood about anesthesia, it is that the safest and most effective perioperative care is built on collaboration, not parallel workstreams. Our shared goal is to provide exceptional, evidence-based care, which requires constant communication, mutual trust and open discussions about risk, particularly for complex or critically ill patients. In my experience, the highest-performing perioperative teams are those where surgeons and anesthesiologists view each other not as consultants working alongside one another, but as equal partners in the care of every patient.
Alvin Stewart, MD. Anesthesiologist and Medical Director of UAMS Health Surgery and Interventional Radiology Center (Little Rock, Ark.): We have a limited supply of anesthesiologists, CRNAs, residents and SRNAs. By having early three-way communication between the facility administration, anesthesia and surgical teams regarding procedure and procedure location changes, surgical and anesthesia staffing schedules may be optimized for efficiency and throughput freeing up more white space for additional procedures and service locations.
Larry Troshynski, CRNA. Nodaway Anesthesia Professionals (Winfield, Kan.): We don’t just wave a magic wand and wake the patient up at the end of the case. We slowly titrate meds down so that they will be on the verge of emergence and try to time it so that there are no delays. If there are delays at the end of the case, we have to titrate back up to be fully “asleep.” Giving us a heads up goes a long way towards making turnovers efficient.
Joseph Vaisman, MD. Anesthesiologist and Associate Program Director at Los Robles Regional Medical Center (Thousand Oaks, Calif.): I wish surgeons understood that anesthesiologists get paid very differently than they do. Medicare and Medi-Cal are our worst payers. There is a 300% to 500% spread between Medicare and Medi-Call and private payers. We need a full efficient day or a solid payer mix.
Lee Weiss, MD. Cardiac Anesthesiologist at Marietta (Ohio) Memorial Hospital: I wish surgeons understood that the greatest value an anesthesiologist provides is often the complication that never occurs, the diagnosis made before anyone else sees it or the intervention that changes the course of a case. It is easy to underestimate the impact of an experienced anesthesiologist who is actively engaged in a patient’s care throughout a procedure.