Clinical Case for Discussion:  As an anesthesia resident, how does your preoperative interview with a patient differ from that of an anesthesiologist with 20 years of experience?

Discussion:  In my second year of residency, I had the pleasure of working with Stanford anesthesia attending C. Philip Larson, M.D., a Past-Chairman of the Department and a Past Editor-In-Chief of our specialty’s leading publication, Anesthesiology.  My rotation was neuroanesthesia, and each evening prior to surgery Dr. Larson and I would make rounds on the wards to meet the surgical patients for the next day. (In the 1980’s almost all patients were hospitalized one night prior to surgery.)

I was surprised and taken aback by the experience, and I never forgot what those patient encounters were like.  Although Dr. Larson always let me do the anesthesia procedures in the operating room, he presented himself at the pre-op interview as the primary physician in charge of the anesthesia care.  When Dr. Larson entered a patient’s room, he sat down on the bed and played a role that was part Santa Claus and part all-knowing, all-loving deity.

Dr. Larson greeted the patient kindly, introduced both of us, and then launched into a comfortable dialogue about any variety of topics, none of them remotely related to the surgery or the anesthesia.  I kept waiting to hear him say, “can you walk up two flights of stairs?” or “do you ever have chest pain?”

These questions were never asked or answered at the bedside.  They’d already been asked and answered and were present in the patient’s chart.  Dr. Larson valued the preoperative interview as a time to connect with his patient, and to establish rapport and comfort between them.  After perhaps ten minutes of such banter, he would switch gears and state that we would be doing the anesthesia care the next day, that we would keep him or her asleep and safe, and give a modicum of detail about what to expect.  He did not perform any detailed physical exam.

Despite the fact that Dr. Larson was a renowned expert witness in the specialty of anesthesia, he did not recite a litany of informed consent risks.  A particular pet peeve of his was the suggestion that an informed consent discussion should include telling a patient of the risk of death.  His opinion on this issue always was, “If you tell the patient that they can die, and then you do something negligent and they do die, your informed consent protects you not one bit from the fact that you practiced below the standard of care.”

In his best-selling book, Blink, Malcolm Gladwell writes that the risk of a doctor ever being sued has very little to do with how many errors they make.  He explains that there’s an overwhelming number of patients who’ve been harmed by shoddy medical care yet never have filed a malpractice claim.  What was the common denominator of the people who do choose to sue?  According to Gladwell, they feel they were treated badly by their doctor.  That even when injured by clear negligence, most people won’t sue a doctor they like.

Dr. Bruce Halperin, a member of the Associated Anesthesiologists Medical Group in Palo Alto and a member of the Stanford clinical faculty, is renowned for his bedside manner.  In the preoperative area, I often hear Dr. Halperin telling joke after joke, and the intermittent bursts of laughter from his patients sometimes make it difficult for me to even hear the conversation with my own patient.  One of our busiest cosmetic surgeons often has Dr. Halperin telephone patients early in the consultative process to discuss anesthesia issues.  A patient later told this surgeon, “I’m not sure if I want to have the plastic surgery, but I sure do want to have the anesthesia!”

As an anesthesiologist, you have 10-15 minutes to complete your medical interview with your patient, and to get them to respect you, to have confidence in you, and yes . . . to like you.

As a resident-in-training, your preoperative interviews may be thick with questions about active medical problems, particularly cardiac, pulmonary, and neurologic questions.  You may perform a rigorous and detailed exam of the airway, lungs, and heart.  And you likely spend ample time explaining the anesthetic technique, alternatives, and risks.

You are trained to do all these things.  Twenty years from now, your interview may not be as conversational and sparse on medical questions as Dr. Larson’s was, but your technique will evolve.

Most pertinent questions have already been asked and answered in the patient’s medical records.  Tailor your interview as appropriate for the patient’s medical co-morbidities and the invasiveness of the surgery.  For a 68-year-old with diabetes and hypertension who is about to have a cholecystectomy, it will be relevant to ask them whether they can walk up two flights of stairs and whether they ever have chest pain.  For a 24-year-old with a negative history who is about to have a knee arthroscopy, a simple “Are you in excellent health?” may suffice.

What about the physical exam?  For experienced anesthesiologists, the assessment of whether the airway may be difficult can usually accomplished in seconds, with examination of the mouth opening and the neck extension.  You will listen to the lungs and the heart, but in the absence of symptoms, it is rare to uncover any information with your stethoscope that changes your anesthetic.

Patients are nervous before surgery.  They welcome both your expertise in medicine and your skills in making them relax.  Experienced anesthesiologists can explain the anesthetic plan and risks in a fashion that will gain the patient’s trust and confidence.

The only procedure most of us do while the patient is awake and unsedated is the insertion of an I.V. catheter.  This is a time when you have the luxury of talking about any topic that is calming to the patient.  Conversations about the patient’s hobbies, work, hometown, or family are all pleasant diversions to enter the realm of Dr. C. Philip Larson, and connect with the patient without talking any further about anesthesia.

In my previous career, I was an internal medicine doctor.  In medicine clinic there are dozens of questions to be asked and answered:  “Where is the pain?  How long has it been there?  What makes it better?  What makes it worse?  Does it move anywhere? . . .”  With a waiting room full of patients, there was little time to ask each patient where they had dinner last night or where their child was going to college.

In contrast, anesthesia practice can provide a wonderful opportunity to relax your patient with well-spun conversation.  My advice to you is to be as much like C. Philip Larson, M.D. as your practice allows.  Try not to be a walking, talking EPIC-checklist when it’s time to connect with your patients.

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:




  1. Hi. I am an anesthesiologist in New England and was googling stuff on TIVA when I came across your blog… I love it! I put you on my favorites bar! I have been an attending since 1994 and everything you say is right on and well written! I feel like I am getting moral support from afar just by reading. The obamacare blog and anesthesia was particularly enlightening…. I am in an ACO model and work in a care team environment with a very politically savvy anesthesiologist leader….suffice to say I will be following your blog! Thank you!


  2. Dr Novak im your new Fan.. i came across with your page by accident and its great…. im a anesthesiology Resident in Mexico…


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