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.
phone 650-465-5997

What can we expect in the next 10 years of anesthesiology? What will be the trends for the future of anesthesiology? I’m writing this in January 2016. God willing, we’ll all be alive and well to reread this in 2026, and find out how many of these predictions about the future of anesthesiology came true.


I’m writing this from the perspective of a busy clinician who has worked as an anesthesiologist in California in both private practice and at a major university hospital for over 30 years. I see 10 trends for the future of anesthesiology as:

  1. Lower income (as adjusted for inflation). There will be multiple causes for this: a) An aging population, with the significantly lower pay for attending to Medicare patients, b) Obamacare and other governmental payment cuts, c) Bundled insurance payments to hospitals, requiring anesthesiologists to negotiate for every nickel of that payment due to them, and d) Corporate anesthesia (see #9 below).
  2. More care team anesthesia and more Certified Nurse Anesthetists (CRNAs). Hospital systems will have increased incentives to perform anesthetics with cheaper labor. Rather than physician anesthesiologists personally performing anesthesia, expect to see CRNAs supervised by physician anesthesiologists in an anesthesia care team, or in some states, CRNAs working alone.
  3. There will be a paucity of new drugs to change the practice of operating room anesthesia. A few years ago I had a conversation with Don Stanski, MD, PhD, former Chairman of Anesthesiology at Stanford and now a leading pharmaceutical company executive, regarding new anesthetic drugs in the pipeline. Dr. Stanski’s reply was something along the line of, “There are almost no new anesthetic drugs in development. The ones we currently have work very well, and the research and development cost in bring an additional idea to market is high. Don’t expect much change in the coming years.” Consider sugammadex, a new drug for the reversal of neuromuscular blockade, recently approved by the Food and Drug Administration. The drug is more effective in reversing a rocuronium or vecuronium block than is neostigmine, but the cost is high. The acquisition cost of the smallest available vial of sugammadex is over $90, far exceeding the cost of neostigmine. In certain instances, faster reversal by sugammadex will be critically important, but for routine cases the cost is prohibitive. This trend of fewer new anesthesia drugs isn’t only a futuristic phenomenon. In my current private practice, I see my colleagues using the same medications that they used 25 years ago: propofol, sevoflurane, rocuronium, fentanyl, and ondansetron.
  4. An aging population, an increased volume of surgery, and an increased demand for anesthesia personnel. As the baby boomers age, there will be an increased number of surgeries on older, sicker patients. Anesthesia personnel will be in great demand.
  5. Anesthesiology will become more and more a shift-work job. A generation ago an anesthesiologist started a case and finished that case. An on-call anesthesiologist came to work at 7 a.m., took 24-hour call, and finished their last case as the sun came up the next morning. Certain instances of this model may persist, but as more anesthesiologist become corporate employees, expect more anesthesia practitioners working 8-hour or 12-hour shifts, just like employees in other jobs.
  6. Increased interest in the specialty of anesthesiology amongst medical students. Although several items on my list may seem discouraging, take heart, because the career of anesthesiology will remain extremely popular. Why? Because the other fields of medicine have problems, too. Bigger problems. Many future doctors will shun the primary care fields of family practice, internal medicine, and pediatrics. The primary care fields offer long days in clinics, dealing with a new patient every 10 – 15 minutes, and they suffer from low pay. Because of the higher reimbursement in procedural specialties, careers in surgery, anesthesia, cardiology, and invasive radiology will always be popular.
  7. Expect improved safety statistics regarding anesthesia mortality and morbidity. Anesthesia has never been safer. See “How Safe is Anesthesia in the 21st Century?” Expect further improvements in monitors, protocols, education, and the analysis of Big Data that will make anesthesia safer than ever.
  8. There will still be a non-zero incidence of anesthesia-related fatalities. There will still be disasters, particularly airway disasters. Some anesthesia clinical situations will always remain extremely difficult and challenging, and human error will not be eradicated.
  9. Large national corporations will continue buying up private anesthesia practices, perhaps eliminating the current model in which groups cover one hospital or one city alone. In the last three months, Sheridan, the physician services division of AmSurg, Corp has purchased the 60-physician, 140-anesthetist Northside Anesthesiology Consultants in Atlanta, and the 240-physician Valley Anesthesiologists & Pain Consultants in Phoenix. In these purchases, senior board members and partners receive seven-digit checks to sell their practice, then all physicians in the practice’s future labor for a discounted wage, perhaps as low as 50% of the prior income. If this trend becomes widespread, this subset of the anesthesia workforce will become low paid practitioners, while the purchasing corporations will make significant profits for their stockholders.
  10. Continued fascination with anesthesia practice, a discipline which makes all surgical treatments and cures feasible. Without anesthesia, there can be no major surgical procedures. Medical care without major surgical procedures is unthinkable. Whether as anesthesia providers, as patients requiring surgery, or just as observers of the process, we will all continue to value and marvel at the field of anesthesia.


The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?


The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?







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.
phone 650-465-5997


Johnny and I ate breakfast together at 6:30 a.m. It was a complex meal—we split a six-pack of powdered sugar donuts from the Seven-Eleven and washed them down with two glasses of orange juice. The talc-like sugar dusted Johnny’s upper lip and the collar of his San Francisco Giants T-shirt. The kitchen was quiet as a library. The only sounds were our glasses clacking against the tabletop. It was Johnny’s first day of school and my first day to report to the local hospital. We were each journeying into the unknown, and the tension connected us.

I broke the silence. “Nervous?” I said.


I didn’t believe it. Johnny’s eyebrows cast dark shadows, shielding his sunken eyes in blackness. I waited a minute for a sequel to his monosyllabic teenage offering, but no conversation followed.

“Want me to walk over there with you?” I said. “Make sure the paperwork is all OK for your transfer?”

Johnny scoffed. “Are you kidding? I’m 17 years old, Dad, not 7. I’ll figure it out.” He pushed away from the table and left the kitchen. I watched him pace back and forth across the living room floor like a skydiver awaiting his turn to jump out of the plane. Then he grabbed the front door knob and said, “I hope this school doesn’t suck, for both of our sakes.” The door slammed shut, and I looked out the front window to see Johnny hopping through last night’s frozen footprint holes in the snow. Steam rose from his wet hair. He wore a fleece turtleneck over a pair of cotton sweat pants, and no gloves, hat, or boots. I watched him bound two stairs at a time up the entryway of Hibbing High School.

I needed to be at Hibbing General Hospital before 7:30. I’d filled out all the necessary paperwork online. I’d already secured my medical staff privileges and my appointment to the anesthesia service. I wanted to arrive early to check out the facilities and meet the people I’d be working with in the coming months.

I dressed myself in a pair of Sorel boots, a North Face jacket, and one of Dom’s Minnesota Vikings knit caps. A puff of wind from the north scorched my face as I headed out into the winter morning. The stark chill woke me up faster than two espressos. The hospital was a three-block hike from Dom’s house, so it made sense to leave the battered BMW on the curb and walk to Hibbing General.

The hospital was an aging three-story building made of yellowed stone. The front doors were tall brown slabs flanked by two white Doric columns. I smiled at the polished surface of the brown wooden doors. I’d worked summers as a maintenance helper at the General during my college years. One day my foreman gave me a can of red paint and told me to paint these very doors. The next day the hospital administrator chewed our heads off for painting the hospital front doors the color of blood. He dispatched me to the front of the building with a paintbrush and a gallon of brown paint. The doors were still brown this very day.

I found the surgical locker room, a small space one-tenth the size of the men’s locker room at Stanford. I selected a set of scrubs off the shelf and changed out of my street clothes. At Stanford the scrubs were bright royal blue. In Hibbing the scrubs were faded green and looked like they’d been in use since the day I was born in this very building.

I was edgy, even though I was overqualified to work at this little community hospital. At Stanford every nurse, doctor, and janitor knew my name. Here I’d have to earn the respect of dozens of people who’d never heard of me. Medical careers don’t travel as well as business careers. A businessman in California could be promoted to a CEO job in Minneapolis, but doctors who moved from one state to another started at the bottom of the ladder, behind physicians who had reputations and referral patterns already established in the new community.

I entered the hallway of the operating room complex. Hibbing General had only six operating rooms, compared to the 40 rooms at Stanford. The schedule for the day was posted on a white board across from the central desk. My old med school classmate, Michael Perpich, the Chief of Staff at Hibbing General, was the surgeon working in operating room #1. Dr. Perpich was repairing an inguinal hernia on a 43-year-old man—a routine case. I could pop in and say hello without distracting Perp from his task.

I put on a surgical hat and mask and pushed open the door into O.R. #1. The operating room was small, a compact 30 feet by 30 feet. The linoleum floor showed brown stains from old iodine spills. The faded turquoise tile on the walls had witnessed thousands of hernia surgeries. Michael Perpich was bent over the patient’s abdomen. He saw me walk through the door, and said, “Nico Antone. The Tone. Get your ass over here.” A surgical mask covered his face, but I knew my friend was grinning.

“They said you needed some help to fix this hernia,” I said.

“You’re a God damned gas-passer. You couldn’t fix this hernia if I held the book open for you.”

“I’m here to see if your hands shake as much as they used to, Perp.”

“I came here straight from the card room at the Corner Bar at dawn. Never felt better.”

“You’re so full of shit.”

“Did you guys get situated over at Dom’s?”

“We did. Johnny wasn’t thrilled about waking up at 6 a.m., but he ran up the high school steps two at a time this morning.”

“So he’s a gunner. Just like his dad.”

“I got by.”

“You opened a textbook once a week in med school, and you still finished number one in our class. I can’t believe you came back. When you left for California you said never wanted to see a snowflake again.’”

“Things change, Perp. My kid needs an upper-Midwest high school diploma.”

“California kid comes to the wilderness to go to the head of the class, eh? I’ll tell you one thing: the Hibbing teachers will shape him up. I had sergeants in the Army who were more mellow than the Hibbing faculty.”

The scrub tech, a blonde woman wearing too many layers of blue eye shadow, said, “My son is a sophomore. He studies four hours every night.”

“Nico, meet Heidi, my right-hand woman,” Perpich said. “She’s my assistant, my psychotherapist, and the encyclopedia of all gossip great and small in the village of Hibbing.”

“Nice to meet you,” I said.

“Heidi, this is Dr. Nicolai Antone, a welcome addition to the anesthesia staff. Dr. Antone and I went to med school together. He was an anesthesiologist in California, but now he’s one of us, the slightly-better-than-average staff of Hibbing General. So you left Alexandra behind?”

“I did.”

“Good move. Not much up here for princesses.”

“You’re married, Dr. Antone?” Heidi said.

“I am. My wife is back in California.”

She fluttered mascara-laden eyelashes at me and said, “Welcome to Hibbing General. I look forward to working with you.”

Perpich looked up toward the head of the operating room table and said, “Bobby, did he get his antibiotic?”

A wisp of a man—narrow and bony—stood at the head of the operating room table in the anesthesia cockpit of machines, monitors, intravenous drips, and drug cabinets. The man said, “She did. One gram of Kefzol at 7:45.”

“Nico, I want you to meet Bobby Dylan, our Director of Nurse Anesthesia,” Perpich said.

My head snapped back. I wondered if I trusted my ears. Bobby Dylan? The same name as the legendary musician? Here in Hibbing?

The nurse anesthetist ignored Perpich’s cordial introduction and said nothing to me. I was miffed. Who did this guy think he was? He was only a nurse anesthetist. Why the ingratiating attitude toward me, a board-certified anesthesiologist physician?

It was a small hospital, and despite my negative first impression I felt compelled to meet my fellow anesthesia colleague. I walked around the operating room table and entered the anesthesia station. A blue paper hat and mask covered Dylan’s face. His sole facial features were the recessed caves that housed his glossy fish eyes, and the speckled black and gray eyebrows that floated above them.

I extended my hand and said, “Greetings. I guess we’ll be working together.”

Dylan turned his back on me. The beep, beep, beep of the patient’s pulse rate hung between us. He reached over and turned the knob on the anesthesia machine that titrated the oxygen flow. He coughed twice—loud, harsh, barking sounds, and said, “We opted out here, Mac.”

“What?” I said. I wasn’t sure what I had just heard.

“We opted out,” Dylan repeated. He still wasn’t looking at me. He picked up his clipboard and made some notations on the patient’s chart with a pen.

I was getting more and more pissed off. My first impressions were confirmed. This guy was a dick. I didn’t care if this was Dylan’s anesthetic, his operating room, and his hospital. I was unaccustomed to this degree of condescension within two feet of an anesthesia machine. He turned up the intravenous propofol infusion and continued to ignore me, even though I was close enough to smell the staleness of his body odor.

I checked the settings on the anesthesia machine and monitors, looking for some sign that Dylan was as incompetent as an anesthetist as he was as a conversationalist. He was using routine concentrations of standard anesthetic drugs. The ECG, blood pressure, and oxygen saturation numbers all showed normal values. Dylan wasn’t a doctor, but at the moment he was delivering a routine anesthetic in a safe fashion.

I thought to myself, Fuck you, you dirtball. If this Bobby Dylan character wanted to be left alone, I was going to leave him alone. I said, “Hey Perp, I’ll catch you when your case is done, OK?”

“Will do. I’ll meet you in the lounge. Give me 30 minutes.”

“See you there.” My feathers were ruffled. It was great to see Michael Perpich again, but if my initial contact with this nurse anesthetist was any indication, my welcome in the Hibbing medical community was going to be as chilly as a January dawn. I made my way to the operating room lounge, a stark room with four walls of undecorated peach-colored wallboard. The sole furnishings were two long tables and a dozen chairs. All the chairs were empty. Sections of the Duluth News Tribune and the Hibbing Daily Tribune were strewn over the tabletops. The aroma of fresh brewed coffee filled the air. I poured myself a cup and selected a glazed doughnut from a platter.

I felt like a midcareer misfit, stuck in somebody else’s workplace. I missed Stanford. On a professional level, this move to Minnesota looked to be a near-death experience for me.

Michael Perpich’s clogs hammered the floor when he walked in. He pinched the back of my neck, snatched two doughnuts for himself, and plopped down in a chair across from me. “It’s great to see you, Tone,” he said. “I still can’t believe it.”

I hadn’t sat eye to eye with Perp for years. With his surgical cloaking removed, he looked ten years older than me. The top of his head had more dandruff than hair, and the creases around his nose and mouth were deep and long. His smile was genuine, and I chose to disregard the ancient appearance of the only acquaintance I had within a thousand miles.

“Glad you’re here,” I said. “I’m counting on you to be my lifeline at this place.” I waved my hand at the desolate room. “Does anybody else work here?”

“Of course. We have a full staff, like any other community hospital, but we’re light on anesthesiologists. Your timing is perfect. Our last two anesthesiologists retired and moved to the Sun Belt in November. We have six nurse anesthetists, but for tough cases we need an M.D. anesthesiologist in town. Now we’ve got you.”

“So the rest of the anesthesia staff is all nurses?”

“Yep. Six nurse anesthetists. They’re a solid group. I haven’t had too many problems with them.”

I was unconvinced. Nurse anesthetists were registered nurses with a year or more of intensive care unit experience, followed by two or three years of training in a nurse anesthesia program. They learned how to anesthetize patients, but they weren’t medical doctors. In some hospitals, anesthesiologists worked with nurse anesthetists in anesthesia care teams, a team model in which one M.D. anesthesiologist might supervise four nurse anesthetists working in four separate operating rooms. Because this hospital had no anesthesia doctors, the nurse anesthetists were working unsupervised.

“What’s the deal with the Bobby Dylan guy?” I asked. “He stopped one step short of open hostility. Is he a prick, or what?”

“Sometimes he is.”

“He didn’t give me the time of day.”

“It’s a turf thing. This is his hospital. You’re an outsider. The guy doesn’t want you here.”

“He’s a nurse. How does he get off giving me a hard time?”

“Minnesota is an opt-out state, Nico. The Minnesota governor opted out of the requirement for a medical doctor to supervise nurse anesthetists. Bobby Dylan can give anesthesia here, just the same as you can, even though he’s not a doctor.”

We opted out here, Mac. The words Dylan had uttered to me. Opted out.

“So it’s legal here for a nurse anesthetist to give an anesthetic without being supervised by a physician?”

“That’s right.”

“That’s substandard care, if you ask me, and it still doesn’t make this Bobby Dylan guy a doctor. If you had enough physician anesthesiologists in town, would you still let jokers like him give anesthetics alone, or would you replace him with a doctor?”

Perpich threw up his hands. “That’s never going to happen, so who cares? Dylan has been here a long time. He hasn’t had any deaths, he’s kept his nose clean, and he’s not going anywhere.”

“Why is he named Bobby Dylan? That can’t be for real.”

Perpich shrugged again. “I don’t know what his real name is, and I don’t care. He showed up in Hibbing 8 or 10 years ago, and his license and paperwork all identified him as Bobby Dylan. I asked him if that was his real name or if he’d changed his name.”

“And he said?”

“He said his name was Bobby Dylan. Period. He dodged any questions about his past. He was a nurse anesthetist in the Afghanistan War. He’s got a wife and a daughter. He plays guitar and sings at a bar downtown. Plays all the original Dylan songs. People tell me he’s pretty talented. Maybe he was a huge Bob Dylan fan and he just wanted to move to Dylan’s hometown, take Dylan’s name, and get a job here. If so, he’s done all three.”

I shook my head. “That’s pretty weird stuff.”

“It gets more weird. He bought the old Zimmerman house.”

“You’re kidding.”


“He’s a psycho,” I said.

Perpich’s eyes twinkled. “Up here, there are a lot of characters. Get used to it. He’ll grow on you, once you accept the fact that he’s your peer.”

“My peer? I’ll never accept that.”

As if summoned by their conversation, Bobby Dylan came in through the doorway, poured himself a cup of coffee, and sat in the opposite corner of the room. He peeled off his surgical hat to reveal a fuzzball of curled black and gray hair. He took out a pen and started filling out a crossword puzzle from the morning paper. His mouth stretched into a long yawn. It was just another day for him. My presence was of no consequence.

“I’m going to make rounds on my patients upstairs on the surgical wards,” Perpich said. “Will you be home tonight?”

“Where else would I be?”

“I’ll drop by. I’ve got some housewarming presents for you.”

“I hope it’s a digital video recorder. Dom doesn’t have one.”

“No DVR. Just make sure you’re hungry.”

“Sounds good. See you later.”

Right after Perpich left, I heard a rumbling voice behind me say, “Doctor Antone?”

I turned. It was Mr. Dylan. His facial expression was a cross between a smirk and an all-knowing smile.

“Yes?” I said, puzzled at the encounter.

“I dissed you back there in the operating room. Sorry about that. I was concentrating on my patient, and no one told me you were coming to town. I expect this place is big enough for both of us. No hard feelings?”

I was suspicious. The curl of Dylan’s upper lip seemed to say, I don’t like you one bit, but I’ll pretend that I do just to fuck with you. Before I could answer, he sat on the tabletop in front of me and asked, “Why does a California guy like you move to the Iron Range?”

“I grew up here. I missed the ice fishing and deer hunting.”


“My son transferred into the 11th grade. We want him to graduate from Hibbing High.”

“Let me guess. You think he’ll be the smartest kid in town.”

“I have no idea. We just got here.”

Dylan twirled a wisp of his moustache between his fingers and thumb. “I’ll bet $1000 you and your kid are gone by next January. This ain’t no place for boys from Californ-eye-aye. No place at all.”

“We’ll adjust.”

“You OK working here, where nurse anesthetists are your equals?”

I bit the inside of my cheek. “I’m not sure nurses and doctors are equal. I expect I’ll get used to the fact that nurses can give their own anesthetics here.”

“Of course you will. Just remember, you’ve got no power over me here. No power at all.” Dylan winked and said, “Now, if you’ll pardon me, I’ve got to go make me some money.”

He walked away, and his words echoed in my ears: No power over me at all. My first impression was reconfirmed. This Bobby Dylan was trouble.

It was break time, and the lounge was filling up. An attractive woman sat down at the adjacent table. She had the palest of green eyes that precisely matched the color of her scrub shirt. She had flawless skin and adorable dimples, and the knack of smiling nonstop as she chatted.

I smiled to myself, and forgot about the onerous Mr. Dylan. The sight of a beautiful woman trumped all of life’s ills.

It really did.


Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.


In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:


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