He was a brilliant anesthesiologist at the top of his career when, one day, he could not intubate a neonate and was worried. The next day, his family thought he did not look well and took him to the emergency room. A CT scan found a brain stem tumor, revealing the cause of his difficulties – “elevated intracranial pressure.” In the course of only 48 hours, his life had changed. Instead of worrying about his patients, his family was trying to find a neurosurgeon who would agree to operate on him. He was only 48 years old.

Another anesthesiologist fell one day while leaving work and later found out his fall and bony fracture was due to a metastatic tumor. He underwent surgery, chemo, and radiation, and his life too had changed. A young anesthesiologist started a first job after a fellowship, but a domestic situation led to stress and loss of life by suicide.

Stories like this are scattered around us and keep reminding us that life is fragile and can change in the blink of an eye. Personal health issues are only one of the several things that can change our life, our career, and affect our loved ones. Other factors that may be life- or career-changing for anesthesiologists include job loss, stress and burnout, bad patient outcomes, and medical malpractice lawsuits. Most of these factors are out of our control.

One may think that clinical competence, passion, and empathy should be enough for an anesthesiologist to thrive as a professional. These traits are the backbone of our profession. Other factors like teamwork are of prime importance too, as anesthesiologists must collaborate closely with surgeons, nurses, and other health care professionals to ensure patient safety. Anesthesia residency training emphasizes development of communication skills and functioning within a team. At times, even when an anesthesiologist is capable of being a team player, implicit or explicit bias by other players in the team can lead to conflict and friction, which may lead to a need for change.

The health care system in the United States is increasingly influenced by economic factors, such as hospital budget cuts or restructuring. A major example from recent history is when the doors were closed at the oldest children’s hospital in Boston (the Floating Hospital for Children) in summer 2022. The department of anesthesiology at this university hospital had a strong pediatric division with an ACGME-accredited fellowship training program. The pediatric anesthesiologists were left scrambling, and a valued training program was lost.

Human life is fragile. It takes almost three decades for one to finish all necessary training before the coveted label of “anesthesiologist” is finally achieved. And this voyage is not solo, as the sacrifices of parents, siblings, spouses/significant others, friends, and children make this journey possible. When an unforeseen event interrupts, it affects everyone.

The December ASA Monitor contains several featured essays that encompass different aspects of the adversities faced by practicing anesthesiologists.

In the article “From Surviving to Thriving – A Burnout Story,” Jeffrey W. Hartwig, DO, offers a very personal story of burnout resulting from stressors in his personal and professional lives, which eventually led to his leaving the field of medicine. After leaving the profession, he adopted several strategies (self-guided as well as professional help) to get his life on track. These strategies were successful. When his old department approached him with a strategy to return to the profession he loves as half FTE, he accepted and began to thrive.

“Navigating the Aftermath of an Unexpected Intraoperative Death,” by Drs. Rima Abhyankar, Alexander Meshel, and Benjamin Hyers, delves into the emotional and psychological burden that anesthesiologists face after experiencing an intraoperative death (IOD), an event that, while rare, is a reality in the careers of most anesthesiologists. Despite their extensive training to manage life-threatening situations, anesthesiologists are often unprepared for the emotional aftermath of a patient’s unexpected death. The shock can shatter the sense of control and invincibility that is often found in anesthesiologists, who operate in a profession built on precision and safety. A lack of preparation and support for dealing with these outcomes can result in overwhelming feelings of guilt, self-doubt, isolation, and even dysfunctional behaviors like insomnia, substance abuse, early retirement, or suicidal thoughts. The article also highlights the “second victim syndrome,” where health care professionals experience emotional trauma after an adverse event, especially in high-stakes fields like ours. Studies show that inadequate support after an IOD can compromise an anesthesiologist’s ability to provide care and result in long-term psychological effects, with some considering career changes. The article advocates for systemic reforms, including the incorporation of discussions and simulations of IOD during anesthesiology training and the establishment of robust emotional and psychological support systems for both trainees and practicing anesthesiologists. By normalizing conversations around IOD and providing better resources, the field can foster a culture of resilience, where anesthesiologists are better equipped to handle not only the medical complexities but also the emotional challenges of their profession.

These two articles are followed by a very thoughtful piece titled “How to Cope When Things Go Wrong,” which explores various personal and professional strategies we can adopt to manage stress, especially after encountering poor patient outcomes. Allen N. Gustin Jr., MD, FCCP, FASA, FCCM, a critical care and palliative care anesthesiologist, shares personal experiences of how patient deaths can have a profound impact, both mentally and physically, on their caregivers. The article stresses the importance of a supportive work environment where colleagues can offer emotional check-ins, provide early relief from clinical duties to process the events, and expedite quality reviews. The author points out that these steps can ease emotional burdens, especially after unanticipated outcomes. The article also delves into the value of mindfulness meditation and self-compassion as critical tools for managing stress and emotional responses to difficult situations. Through years of practice, the author has found mindfulness meditation to be an essential part of reflection and emotional management, particularly after patient care failures. Self-compassion, though more challenging, helps counteract self-criticism and promotes emotional healing. The importance of self-care is also underscored, with the author outlining changes to improve physical health, sleep quality, and personal relationships as key to overall well-being. Additionally, the article recommends professional development in bioethics and the disclosure of adverse outcomes, which can help health care professionals better navigate difficult conversations with patients and families. Ultimately, the message is that each individual copes with stress differently, and we all must actively work on improving emotional resilience. By addressing these elements, health care professionals can better manage their emotions and prevent burnout.

The last featured article in this special issue is very practical. In “Help, I’ve Been Sued! A Practical Guide to Dealing with a Lawsuit,” Drs. Jason Sung Chi, Aaron N. Primm, and Naileshni S. Singh provide a step-by-step overview of what happens when an anesthesiologist is faced with a malpractice lawsuit. The article summarizes the do’s and don’ts when a legal case is at hand, and the authors walk the reader through the commonly experienced steps of the legal process, including what to expect and how to do it right.

Stroke is a national and global issue – compounded by an aging patient population with progressive comorbidities such as hypertension, diabetes mellitus, heart disease, and cardiac arrhythmias. Almost 800,000 people suffer acute stroke each year in the United States (Circulation 2023;147:e93-621). Many of these patients will require anesthetic care for interventional and diagnostic procedures related or unrelated to this stroke event. As experts in perioperative medicine and patient safety, it is our responsibility to understand the physiologic aberrations that occur during anesthesia that leave our patients vulnerable to further injury. In this short update, we will describe the current epidemiologic state of stroke, what neurologic risks these patients may incur during the perioperative period, and practices that may optimize this population’s brain health.

For reference, stroke refers to the cerebrovascular disease of acute malperfusion to the central nervous system. There are several types and etiologies of cerebral stroke, but we will mostly be referencing ischemic stroke for the purposes of this update.

Being involved in a medical malpractice claim is not an uncommon experience among the practicing physicians in the United States. The annual rate of paid malpractice claims across all specialties is 14.1 per 1,000 physician-years, while anesthesiologists have a lower rate of 11.7 per 1,000 physician-years in the U.S. (JAMA Intern Med 2017;177:710-8). A recent study found that 41.5% of anesthesiologists over the age of 55 had been sued in their career (Policy Research Perspectives 2023:13). To most physicians, a medical malpractice lawsuit is an unpleasant introduction to the legal system, and with little formal training in litigation, physicians are understandably apprehensive and anxious when sued. In this article, we provide a brief, guided tour through the key steps of a lawsuit with the goal of demystifying the litigation process and empowering you to make sound decisions.

A medical malpractice lawsuit is a civil legal action and a petition for financial compensation for alleged damages caused by a perceived wrong (either an action or inaction by a medical provider or medical team) to which the defendant is obliged to respond. If you are served with a lawsuit, your first step is to inform your liability insurance company, which will then assign an attorney to your case. In an academic practice setting, you may be notified of a claim through your hospital’s medical-legal department. At this stage, you may be confused, angry, and in disbelief, but you must stay grounded and disciplined: don’t contact the patient directly, don’t alter or addend medical records related to the case, and don’t discuss the case with anyone other than your attorney. You may receive a subpoena that requires you to preserve and submit all documentation related to the claim; refer this to your hospital’s medical record department. You may be required to notify your group or your hospital about the lawsuit, so review your contracts to see if any notification clauses exist. If your case was discussed at an M&M conference, rest assured, these proceedings are typically protected from discovery. Finally, seek out mental health services or counseling as needed to deal with the inevitable stress that the lawsuit will cause.

Next, you’ll meet with your attorney and discuss what you recall about the case. Not all attorneys are alike; you’ll want a fully engaged, quick learner who is experienced in medical malpractice. A good working relationship is important because you will be spending a lot of time with your lawyer and their support staff. If you’re not entirely satisfied, ask your insurer for other options, as they typically work with a roster of attorneys – but make this move early.

In some cases, your attorney may file a motion for summary judgment to dismiss the case based on the initial facts, but this is only granted if the lawsuit is deemed baseless with no facts in dispute. In other instances, your case may be sent to mandatory arbitration as required by the patient’s health insurance contract.

Soon after a lawsuit is filed, discovery begins. Discovery is the process of gathering and exchanging information from and between parties. Medical records, testimony, and depositions will be obtained because these materials are reasonably thought to produce admissible evidence. This process can take months, if not years. After receiving the medical records, you and your lawyer will go over every page in painstaking detail, scrutinizing the meaning of every word, check mark, and comma.

In nearly all cases, each party will retain an expert witness. Your expert witness will review your case and provide an opinion as to whether the standard of care was met. Unsurprisingly, academic credentials and lengthy experience are sought-after qualities in an expert. Request to review your expert witness’ CV and ask yourself, “Is this someone who is qualified to comment on my care?” By being proactive and involved, you can play a role in your defense. If you’re not satisfied with the proposed witness, an alternative can usually be found. You will not be speaking with the expert witness; such communication is not protected by attorney-client privilege and is therefore discoverable. The expert witness will produce a written report in which they conclude whether your actions met (or did not meet) the standard of care. Additionally, a separate medical expert may be retained for the purpose of physically examining the plaintiff and offering an additional nonbiased opinion about the plaintiff’s physical condition. Other retained experts may calculate the estimated financial damages and the patient’s needs for short-term and long-term care due to the claimed injury.

Depositions are another critical element of a lawsuit and should be taken seriously. A deposition is a recorded interview where a witness is questioned one-on-one, under oath, by the opposing attorney. The deposition occurs in-person or via video conference with you, your attorney, the plaintiff’s attorney, and a court reporter. It is important to be truthful, professionally dressed, and prepared; however, don’t bring any notes, because anything on the table in front of you could be subpoenaed by the opposing counsel. The plaintiff’s attorney will ask questions for the ostensible purpose of gathering information, but some questions will be asked in a manner that is intended to provoke a reaction or cause you to “slip up.” You may be asked about documents or other evidence, so be familiar with all the records relevant to your case. Your attorney should coach you extensively in the weeks leading up to the deposition; if they don’t, you should ask that they do so. Be careful not to appear overly rehearsed, inflexible, or robotic – the key is to appear credible.

After discovery is complete, you and your attorney will review the entire case, assess its likelihood of prevailing, and discuss whether to settle or proceed to trial. Most cases are settled before trial because it avoids the cost, time, and unpredictability of taking a case in front of a jury. Many lawsuits are dropped (or defendants are dropped) before this stage, and among the cases that go to a jury trial, studies have found that the defendant (i.e., physician) prevails in most cases.

Cases that involve a monetary settlement or jury award, regardless of the amount, are automatically reported to the National Practitioner Data Bank (NPDB). The NPDB was established in 1986 and is administered by the U.S. Department of Health & Human Services; it stores the names of medical practitioners who have had medical malpractice settlements or judgments against them. The NPDB is primarily intended for use by hospitals and institutions but is accessible to the public with practitioner identities anonymized. Reporting to state medical boards varies by state. For example, in California, settlements or judgments greater than $30,000 generally need to be reported to the state medical board; on the other hand, Illinois, home to the ASA headquarters office, has no minimum threshold, and all monetary settlements are reportable.

You may be sued in your career, and dealing with a lawsuit is aggravating and stressful. However, you can take practical steps to familiarize yourself with the litigation process and increase your engagement in it. By taking these steps, a lawsuit, like many other life challenges, can be managed and overcome.

Disclaimer: The following article reflects the opinions of the writers. It does not necessarily reflect the views of the ASA, and it does not constitute legal advice.

As the patient’s blood pressure and heart rate precipitously drop, you, the anesthesiologist, are becoming tachycardic. You take a deep breath and spring into action. Years of education, training, and complex cases have prepared you to intervene. You call for help, start fluids, and administer life-saving medications. Nothing seems to be helping. Before you know it, you’re asking the surgeon to start chest compressions. You perform countless rounds of ACLS, explore every single “H and T,” and despite your best efforts, your patient dies. You speak the words you never thought you would have to say: “Time of death: 19:42.” But what happens next? How are you supposed to feel or act or do your job? When should you talk with the patient’s family? When should you debrief with your team? How do you move forward?

Anesthesiologists function at the intersection of life and death. Medical school, residency, and years of practice prepare you to prevent the worst – to intervene and save the day. But what happens when it’s not enough? We are rarely taught how to process the aftermath of losing a patient in the OR. We are in a profession founded on safety, control, and precision; however, the shock of an intraoperative death, especially when it is unexpected, can shatter the illusion of invincibility, leaving behind immense feelings of guilt, doubt, and isolation.

While intraoperative death (IOD) is never an expectation, it is the ultimate outcome that a well-prepared anesthesiologist seeks to avoid. IOD, while rare, is an event that will happen in the careers of most anesthesiologists, yet training rarely focuses on the management of the aftermath (Anaesthesia 1997;52:477-82). One study indicates that intraoperative CPR in noncardiac surgeries occurs in 0.03% of cases (PLoS One 2020;15:e0225939). Few anesthesiologists discuss these outcomes, but an intraoperative death can have significant psychological impact on the anesthesiologist involved. It has been suggested that inadequate support following an IOD could lead to constant internal repetition of events, dysfunctional behavior, insomnia, substance abuse, early retirement, and even suicide (When Things Go Wrong. 1990). Furthermore, anesthesiology trainees, like trainees in other specialties, do not have the same breadth of experience as their attendings and may be unequipped or unsupported following a death, and every person may cope with the adverse event in different ways.