Each year, more than 40 million anesthetics are provided to patients in the United States. Between changes in payment patterns, supply chain challenges, and increasing demand for anesthesiology services, anesthesiologists are under increasing pressure to do more with less. This drive to increase throughput, minimize costs, and optimize profitability has significant downstream effects for the active anesthesiologist and can lead to adverse outcomes for patients, physicians, nurses, and the health care system as a whole. Operations research, an applied discipline of using quantitative or qualitative models for systems decision-making, has emerged as a frequently used resource for analysis of the complex variables in clinical practice. While its use is perceived as valuable by business entities, clinicians are often not included in determining and considering the specifics of analysis in operations research. The exclusion of physicians, particularly anesthesiologists, in this process can result in excessive production pressure and can lead to unsafe clinical environments, where a failure in protection of patient safety and in delivery of standard of care may occur. In this article, we consider the relationship between production pressure, patient safety, and clinician well-being. We also outline how operations research may inform or undermine efforts to balance these priorities.

While anesthesiologists tend to prioritize patient safety, patient experience, and achieving clinical excellence, nonclinical stakeholders and managers often approach health care using a different framework. In traditional operations research, hospitals and care systems are modeled purely as processing operations with inputs, outputs, and activities. While this approach may be effective in manufacturing cars or other widgets, reducing health care to viewing patients and clinical encounters as numbers and throughput is often problematic. Employing this type of strategic framework using fixed concepts of resources and outcomes is frequently inadequate in capturing the complexities of health care delivery, which include patient expectations, human workforce factors, system inadequacies, and unpredictability. The importance of building in perspectives outside the usual capacity, costs, input, and output variables is especially important, as value-based assumptions that often remain unacknowledged are built into models behind the scenes. There is hope, however, that increased involvement of anesthesiologists in operations, management, and inclusion of more diverse perspectives and financials of successful output beyond the financial performance currently being measured will result in enhanced potential to balance strategic goals with optimal clinical practice.

Efficiency is a necessary priority to meet demand for surgical care, yet the resulting production pressure can negatively affect anesthesiologist well-being. Production demands manifest in different ways, including pressure to abbreviate evaluations of complex patients, to avoid canceling or delaying surgeries in patients who have not been medically optimized, and to limit the amount of time engaging in critical humanistic elements of patient care and patient experience. The result is that physicians’ values, sources of professional satisfaction, and ethical commitments are deprioritized, if not completely excluded from consideration in the system of health care delivery, often leading to moral distress and moral injury. Moreover, production pressure is superimposed upon other stressors that are intrinsic to anesthesia care delivery. The predictable consequence of this dynamic is burnout, a condition of emotional exhaustion, depersonalization, and decreased sense of personal accomplishment. Although these demands are not at all new, their consequences have become clearer in the setting of the COVID-19 pandemic and limitations in the supply of anesthesiologists. It is now estimated that nearly 60% of anesthesiologists are at risk of burnout, and recent evidence indicates major risk factors for burnout include perceived lack of support at work, working more than 40 hours per week, and perceived staffing shortages. Burnout has measurable effects, including an increased likelihood of engaging in unprofessional behavior, committing medical errors, and leaving the profession entirely.

A growing body of evidence validates concerns that production pressure can detract from the patient experience and jeopardize patient safety. An emphasis on production and perioperative throughput often necessitates the use of higher anesthesiology staffing ratios and increased numbers of after-hour surgeries, which consequently results in higher rates of clinician handoffs.

Higher anesthesiology staffing ratios are evidenced to be associated with higher rates of patient morbidity and mortality. There is a 14% increase in mortality and morbidity in anesthesia care team models when anesthesiologists supervise three to four overlapping operations compared to supervising one to two overlapping operations. The ability to be present for critical portions of cases can be jeopardized by increasing the number of rooms supervised by the same anesthesiologist. In one study, even with a supervision ratio of 1:2, there was a 35% incidence of lapses in the ability to be present for critical portions, particularly at the start of the day.13 This same study found that at a ratio of 1:3 supervision, it was not possible for an anesthesiologist to start all three cases simultaneously and be present for all critical portions of each case.

Production pressure adversely impacts patient safety and patient satisfaction, particularly when it leads to after-hours surgery. In a large meta-analysis, after-hours surgery was associated with more than 30% higher rates of mortality and morbidity for patients as compared to daytime cases. Further, in an analysis of 51,676 surveys from a large multihospital practice, one of the few factors identified that was associated with low patient satisfaction was surgery occurring at night.

“Without attending to tensions between production pressure, patient safety, and clinician well-being, efforts to optimize throughput may increase health care costs and deprive physicians of the conditions needed to deliver safe care.”

Although there is a widespread perception that overlapping surgeries increase productivity, there is little evidence to support such a claim. In a recent review of observational studies, there was no evidence of increased productivity in overlapping surgeries as compared to two surgeons working in parallel. In fact, overlapping surgery was associated with longer surgery duration. Further, it was found that the more surgeries overlapped, the more risk there was that the overlap would occur during “critical portions” of the other surgery and result in greater risk of patient harm. While overall morbidity and mortality is not increased with overlapping surgery, overlapping surgery was associated with higher mortality and complications in high-risk patients.

Production pressure, leading to higher case volumes and after-hours surgery, also contributes to higher rates of anesthesiologist and other clinical handoffs. Handoffs that occur during anesthetic care are routinely complex and, if done improperly, can lead to adverse postoperative outcomes. Poor handoffs and poor communications are root causes of 75%-89% of sentinel events. Intraoperative clinical handoffs are evidenced to be associated with an increased risk of mortality, major complications, delayed extubation, postoperative delirium, and controlled drug discrepancies.

The detrimental effects of production pressure on patient safety and clinician well-being also have a significant negative financial impact. Notably, operations research models often fail to consider or measure the cost of medical errors and physician burnout, which result from production pressure. Although the cost of medical errors varies depending on the error and patient harm, there are significant costs with each medical error. Surgical site infections and severe pressure ulcers cost approximately $30,000 in additional index stay costs per harm. Medication errors alone can cost up to $111,727 per error.21 Production pressure may lead to physician burnout, which can lead to physicians reducing their clinical hours or leaving medicine altogether. The annual economic cost associated with burnout related to turnover and reduced clinical hours is estimated to be $7,600 per employed physician per year.22 $4.6 billion in excess cost related to physician turnover and reduced clinical hours is attributable to burnout each year in the US. These “hidden” costs of production pressure should be measured and considered in operations research.

Production pressure and the intense push to maximize financial efficiency of the health care system will continue to be a reality of clinical practice for the foreseeable future. Without attending to tensions between production pressure, patient safety, and clinician well-being, efforts to optimize throughput may increase health care costs and deprive physicians of the conditions needed to deliver safe care. More research is needed surrounding effective use of operations research and management in a way that upholds physicians’ responsibility to patients, prioritizes excellent patient care, and preserves clinician well-being. One critical step for the future is the inclusion of anesthesiologists to guide management and decision-making, as well as influencing the selection of model inputs and outcome metrics for operations research and models. With increased representation of the physician perspective and more thoughtful use of operations research, our specialty may finally note steps in the right direction to appropriately balance production pressure and our commitment to excellent patient care.