Clinical Case of the Month:  The head of your anesthesia group tells you that both the surgeons and the fellow anesthesiologists in your group want you to work faster, and if you do not, you will not make partner in that group.  You are worried about succumbing to “production pressure.”  You don’t want to work faster.  What do you do?

Discussion:   At the end of your day in the operating room, the most important issue is the safe medical care of each patient you were asked to consult on.  Patients don’t care if you were a racehorse or a turtle; they only care about their results.  Your malpractice insurance company doesn’t care if you were a racehorse or a turtle; they want you to practice at or above the standard of care, and not get sued.

I refer you to the article “Production Pressure in the Work Environment, California Anesthesiologists’ Attitudes and Experiences,” by David Gaba and Steve Howard of the Stanford faculty (Anesth, 1994 Aug;81(2):488-500).   The authors mailed a survey to California anesthesiologists, seeking their responses to questions pertaining to production pressure.  The authors noted that “Every modern industrial activity involves a balance between production efficiency and safety.”  They defined production pressure as “overt or covert pressures and incentives on personnel to place production, not safety, as their primary priority.”

Fifty-four per-cent of respondents agreed they had made an error attributable to fatigue, and 63% suggested that they had made errors because of the work load within a case.  Most respondents believed they had a duty to cancel cases if necessary, but 35% indicated that it was possible they would lose their job if they canceled too many cases.

The types of pressure were divided into two categories:  internal pressures (pressures anesthesiologists put on themselves), and external pressures (pressures from surgeons, family, colleagues, or administrators).  The greatest internal pressures were:  a) to avoid delaying surgery, b) to get along with surgeons, and c) to avoid litigation.  The greatest external pressures were:  a) from the surgeon, to proceed with a case instead of canceling, b) from the surgeon, to hasten anesthesia procedures, and c) from administrators, to reduce turnover time.

Fee-for-service respondents reported more internal pressure than did salaried practitioners to:  maximize cases (P=0.0007), accrue income from high paying cases (P=0.0001), and avoid litigation (P=.0002).

I worked a short stint in a salaried anesthesia job with Kaiser in 1986, before I began working in my current arrangement of fee-for-service (FFS) practice.  Production pressure exists, and I can attest that it is more apparent in FFS practice.  In FFS practice, you have incentives to proceed with cases rather than cancel them, to turn over rooms quickly rather than take a 30-minute lunch break, and to keep your surgeon-customers happy rather than fight with them over cancellations.

I discussed today’s question with other anesthesiologists in top Bay Area FFS practices.  Among their expectations for new hires is that the individual will possess The Three A’s, of Ability, Availability, and Amiability.  Part of the Ability ingredient is the talent to multi-task, that is, the ability to work with your hands, do paperwork, think, plan anesthetics, and monitor your patient simultaneously.

Some anesthesiologists are racehorses, and some anesthesiologists are turtles.  Consider this:  All else being equal, the turtles will not last in FFS job opportunities.

Surgeons in private practice in are faster than surgeons in residency.  When you graduate and enter the private practice of anesthesia, you will have to speed up to succeed.  The message here is a wake-up call:  Don’t stand in the middle of the operating room and complain about production pressure.  Work as efficiently as you can.  Do not take short-cuts that endanger your patient, but get the job done.

If it sounds like I am applying production pressure with my comments, you may be right.  Safety is the number one goal, but high production is an expectation, and not an unreasonable one.

The years of residency and fellowship are the time to hone your skills.  Attempting to work at an efficient pace during the first weeks of your first FFS job will be impossible if you haven’t valued efficiency in your training.  If you are a turtle, will you lose your job?  I know of several anecdotes where private FFS anesthesia groups washed out promising candidates because they were too slow for the private world.  The candidates spent too much time starting IV’s and other lines, getting their patients to sleep, placing regional anesthetics, waking their patients up, taking longer-than-expected breaks between cases, and arguing with surgeons instead of getting patients anesthetized.

Some surgeons are better than others.  Anesthesiologists, nurses, and OR techs all know which surgeons possess excellent judgment and are skilled with their hands.   In the same light, surgeons, nurses, and OR techs all know which anesthesiologists possess excellent judgment and are skilled with their hands.

You want to be one of the anesthesiologists they admire.

If the pace of the FFS world feels unsafe to you, I would advise you to find a different job model, perhaps a salaried job at a more languid tempo.  In a FFS practice, you need to be both safe and efficient.

Introducing …,  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.

The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:


Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.


5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
prabha venugopal (chicago, il USA) – See all my reviews
Verified Purchase(What’s this?)
Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre. PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press, January 4, 2015

“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)

Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.

Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.

Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.

The Physician’s Late-Night Reading List

Two Pritzker alums pen captivating tales

By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine

For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.

Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.

Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”

One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.



The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80

“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.

From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”

After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.

“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”

Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:


This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.

Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.

Rick, I can’t wait for your next book. Bravo!

Hibbingite writes twisted medical tale

HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.

Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.

“The dialogue is sometimes funny, and there are lots of plot twists,” he said.

Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.

“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”

Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
Deann Brady (Sunnyvale, CA USA) – See all my reviews
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”


allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.

Learn more about Rick Novak’s fiction writing at rick by clicking on the picture below:



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