You’re an attending anesthesiologist. You enter another colleague’s operating room to give him a bathroom break during his 6-hour plastic surgery case, and you find him reading and tapping on the screen of his iPad. What do you do?

Discussion:  Is it OK for the anesthesiologist to be reading in the operating room? Is it OK for him to be referencing the Internet? Answering email? Sending text messages on his smartphone? Or should that anesthesiologist be staring transfixed at the monitor screen for hour after hour, maintaining flawless vigilance?

In the Anesthesia Patient Safety Foundation Newsletter Summer 1995 edition, Dr. Matthew Weinger discussed the issue of reading in the operating room. He emphasized that there were no scientific data on the impact of reading on anesthesia provider vigilance or task performance. He cited data that anesthesiologists are ‘idle’ during 40% of routine cases. He asserted that “anesthesia providers read during these idle periods to prevent boredom, and that boredom was a problem of information underload, insufficient work challenge, and under-stimulation…Adding tasks to a monotonous job may decrease boredom and dividing attention among several tasks (time-sharing) may, in some circumstances, actually improve monitoring performance.” Weinger concluded that, “in the absence of controlled studies on the effect of reading in the operating room on anesthesia vigilance and task performance, no definitive or generalizable recommendations can be made. The decision must remain a personal one based on recognition of one’s capabilities and limitations. From a broader perspective, the anesthesia task including associated equipment must be optimized to minimize boredom and yet not be so continuously busy as to be stressful.”

In the Anesthesia Patient Safety Foundation Newsletter, Fall 2004 edition, Dr. Terri Monk opined that reading in the OR seriously compromised patient safety. She was opposed to reading for the following reasons:

  1. Reading diverts one’s attention from the patient.
  2. The patient is paying for the anesthesiologist’s undivided attention, and most well-informed patients want to know if the anesthesiologist plans to turn over a portion of their anesthesia care to a nurse or resident. If we are obliged to honestly answer that concern, then, shouldn’t we also be obliged to inform the patient that we plan to read during a portion of the anesthetic?
  3. Reading is medico-legally dangerous. Dr. Monk wrote, “Any plaintiff’s attorney would love to have a case in which the circulating nurse would testify, ‘Dr. Giesecke was reading when the cardiac arrest occurred. Yep, he was reading the Wall Street Journal. You know he has a lot of valuable stocks that he must keep track of.’ It is possible that if anesthesiologists informed their malpractice carriers that they routinely read during cases, the companies might raise premiums or cancel malpractice coverage.”
  4. The practice of reading in the OR projects a negative public image. Nurses, technicians, and surgeons may think the anesthesiologist is less professional.

A 2009 study (Slagle JM, Weinger MB, Anesthesiology 2009 Feb;110(2):275-83, effects of intraoperative reading on vigilance and workload during anesthesia care in an academic medical center) looked at 172 selected general anesthetic cases in an academic medical center. Vigilance was assessed by the response time to a randomly illuminated alarm light. Reading was observed in 35% of cases. In the 60 cases that involved reading, providers read during 25  +/- 3% of maintenance time but not during induction or emergence. Vigilance to the alarm light was no different between readers and non-readers.

Miller’s Anesthesia (7th Edition, 2009, chapter 6) states, “Although it is indisputable that reading can distract attention from patient care, there are no data at present to determine the degree to which reading does distract attention, especially if the practice is confined to low-workload portions of a case. Furthermore, many anesthetists pointed out that reading as a distraction is not necessarily any different from many other kinds of activities not related to patient care that are routinely accepted, such as idle conversation among personnel.”

A 2012 study (Jorm CM, Anaesthesia Intensive Care. 2012 Jan;40(1):71-8, laptops and smartphones in the operating theatre – how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction?) concluded there were no data concerning the effects of the use of laptops and smartphones in the operating theatre on anesthetist performance, and that these devices were now in frequent use. They discussed the use of laptops and smartphones in regards to the two pertinent issues of vigilance and multitasking. There were data that in some circumstances the addition of a secondary task (i.e. using a laptop or smartphone) during periods of low stimulation can improve vigilance and overall task performance, but the workload and the nature of the secondary task were critical. The authors made the following points regarding the nature of anesthesia work and the factors that affect performance in anesthesia:

  1. Anesthesia involves multi-tasking and the maintenance of situational awareness. Studies have shown that attending to a range of tasks simultaneously is a key characteristic of anesthetic practice, and that anesthetists are superior to non-anesthetists in performing additional tasks while monitoring patients.
  2. Anesthetists typically only glance at monitors. Covert observations of anesthetists in British Columbia revealed subjects spent less than 5% of their time observing the monitoring display. This was made up of brief glances (1.5 to 2 seconds duration) occurring 15 – 20 times during each 10-minute segment of time.
  3.    Anesthetic work is reduced during prolonged maintenance, potentially resulting in boredom and/or secondary activities being undertaken. The maintenance phase in some anesthetics (typically cases of longer duration, lower complexity and where the patient is stable) may be a time of low workload and infrequent task demands. In a study of 105 anesthesia clinicians, half reported being bored infrequently, but 90% admitted to occasional episodes of extreme boredom. Boredom can result in severely decreased vigilance if the anesthetist is suffering from sleep deprivation.
  4.    The authors concluded there was no evidence to support a blanket prohibition on the use of smartphones and laptops in the operating theatre, and there was good reason to avoid edicts that are not supported by solid evidence. They stated, “There is no doubt that reading or computer usage gives the appearance of being less attentive, even if there are no measurable effects on routine care…Computer and phone tasks that also require immediate responses appear to provide a greater risk than reading (whether from a book or screen). While boredom may be cognitively unpleasant, there is no evidence of anesthetist boredom (in the absence of sleep) harming patients.”

I recently attended the American Society of Anesthesiologists national convention in San Francisco. At the conclusion of the meeting, the ASA emailed me a full text edition of the Refresher Course lectures as an email attachment, in a format designed to be downloaded onto a computer. Like myself, more than 10,000 anesthesiologist attendees of the ASA meeting will now have access to the Refresher Course curriculum on their laptops or iPads. Will some of them read these Refresher Courses during the stable maintenance phases of anesthetics in their operating rooms? Perhaps.

Returning to the Clinical Case for Discussion above, what will you do about your colleague you discovered using his iPad in the operating room? My guess is, based on what has been published in the anesthesia literature, you’ll give him the bathroom break as intended, and say nothing about his use of the iPad in the operating room.


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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