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.

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.


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: