99% BOREDOM

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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A familiar adage states that the practice of anesthesia is 99% boredom and 1% panic. In this month’s issue of our specialty’s premier journal, Anesthesiology, Dr. Tjorvi Perry authored an article titled, “Standing Back: Attentive Observations from the Operating Room,” in which he takes an insightful academic anesthesiologist’s view of the 99% boredom time of intraoperative anesthesia care. Dr. Perry writes, “There’s an old joke in anesthesia that it is 99% boredom and 1% sheer terror. Anesthesiologists are well trained to know exactly what to do during that 1%. Less noticed is what happens during the 99%: how much we observe, how much we shape our surroundings. To outsiders, our stillness may seem like disengagement, but it is in fact vigilance, a posture of watching, anticipating, and preparing.”

The author discusses the “full choreography of care” which goes on during that 99% of time. In addition to being a practicing anesthesiologist, Dr. Perry is a bioethicist, with a particular interest in ethnography. Ethnography is defined as “the scientific description of the customs of individual peoples and cultures.” Most anesthesiologists, myself included, have never considered the practice of operating room anesthesia in this context.

Certainly there is a culture in the operating room, consisting of multiple rituals and relationships, for example, between surgeon and anesthesiologist, surgeon and nurses, surgeon and scrub tech, anesthesiologist and nurses. A bioethicist/academic anesthesiologist like Dr. Perry may examine and perform research regarding this culture and these relationships. Most of us who work in operating rooms simply interact and experience the workplace as we find it.

Dr. Perry asserts that the anesthesiologist’s attentiveness to operating room culture during the 99% boredom portion of anesthesia care is important because of 1) patient safety and clinical outcomes; 2) team dynamics, so that anesthesiologists can help foster trust, a cornerstone for a healthy work environment; and 3) ourselves, because the same attentiveness that supports our patients and colleagues also helps us notice the strain of our work.

Dr. Perry concludes that “We are not only technicians or problem solvers, but observers, integrators, and contributors to the culture of care.”

Dr. Perry offers this advice to young anesthesiologists: “For those early in their careers, start by noticing what you are already noticing. After a case, take time to reflect on how the room functioned, what was said or left unsaid, who spoke, who remained silent, and why.”

He offers this suggestion to experienced anesthesiologists: “For those with years in the operating room, consider coaching through this lens. Share not just clinical judgment but cultural insight—what you have learned about navigating tension, reading team dynamics, and recognizing complexity. Make space for these observations in debriefs, huddles, and trainee feedback by asking, How did that feel? What dynamics shaped how we worked together?”

As an anesthesiologist who has practiced physician-only anesthesia for forty years and has personally administered over 30,000 anesthetics in both community and university settings, I’d offer these insights regarding what I’ve learned about what it’s like to be in the operating room for those potentially boring hours:

The most important aspect of the 99% boredom hours of maintenance anesthesia care is to remain vigilant to patient care, even though the vital signs are usually quite stable, and the physiology may not be changing appreciably. Paying attention to culture, rituals, and relationships aren’t bad things, but they are very much secondary goals.
In my first year of anesthesia residency, during the stable maintenance phase of my first 4-hour tedious anesthetic, my attending remarked to me, “So, are you of a contemplative nature?” This was both prescient and relevant, because so much of intraoperative anesthesia care requires you to just hang in there, watching and observing, managing small things and big things, sometimes for many hours. This pace of a workday is not for everyone. It would drive many people crazy to have a job like ours, cooped up in a windowless room keeping people alive minute to minute.
A demonstrative anecdote: Years ago, I was able to bring my teenage son into the operating room to observe a shoulder arthroscopy surgery while I was doing the anesthetic. He was interested in medicine, and it was an opportunity for him to see operating room care on the front lines. In the break room after the surgery, he remarked, “In your job, most of the time it seems like you’re not doing much.” One of my experienced anesthesia colleagues overheard the conversation, and said, “If you see an anesthesiologist working hard, you’ve got a real problem!” Indeed, there’s a lot of sitting and standing around in stable cases in operating room anesthesia care. Stability, and lack of observable excitement, are very much desirable.
The 99% boredom phase of anesthesia care is significantly different in community/private practice than it is in a university practice such as Dr. Perry’s. In a university operating room, a professor is supervising a resident anesthesiologist. This is an appropriate setting for teaching and conversation about the patient’s medical care, comorbidities, the surgical procedure, the pharmacology, the monitoring, and anesthetic options. In community/private practice, the absence of teaching removes these rituals, discussions, and relationships.
Is there a way for an anesthesiologist to get out of sitting or standing in the operating room for hours and hours, day after day? It’s probable that one of the reasons the anesthesia profession created the role of the Certified Registered Nurse Anesthetist and/or the Certified Anesthesiologist Assistant was because the maintenance phase of anesthesia was stable, usually easy, and sometimes boring. Rather than have an MD remain present the entire case, having a CRNA or CAA remain in the operating room instead seemed a reasonable alternative. An additional important reason for the creation of CRNAs and CAAs was the invention of the anesthesia care team, in which one physician anesthesiologist could cover two, three, or four operating rooms simultaneously, instead of manning just one.
In the 21^st century, anesthesiologists can access the internet during the maintenance phase of anesthesia care. This makes it possible to access any medical knowledge relevant to patient care, and can also ease any boredom. Access to the internet is a fact of modern anesthesia care.
I would never describe the science and art of anesthesia as boredom. As anesthesiologists, we conduct both a physiology lab and a pharmacology lab during every case. Our interactions with patients, surgical and nursing colleagues are rich and invaluable. If you love being an anesthesiologist, you’ll find anesthesia practice interesting, even the mid-flight aspect of each surgery.

In our careers, both the 1% panic moments and the 99% boredom hours have distinct challenges. Individuals interested in a lifetime practicing anesthesiology will hone the skills required for both the emergencies and the tedium if they want to thrive and have success in our profession.