Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

These things take time

Let me tell you a little about what goes on behind the scenes during a typical case that I do quite often:  anesthesia for lung surgery. The surgeon’s goal is to remove all or part of a patient’s diseased lung, often because of cancer.

The first step involves my interview and physical examination of the patient. Next, I start the IV if the patient doesn’t already have one, and give appropriate premedication — for example, to help the patient relax, or to prevent nausea. Then the nurse and I bring the patient into the operating room, assist the patient in moving from the stretcher to the OR table, attach appropriate monitors for heart rate and blood pressure, and position the patient comfortably with warm blankets. While I’m busy with these tasks, the surgical team is setting up the operating room, counting instruments and making sure that all the equipment is ready. All this takes at least 20 minutes, often longer. None of it requires the surgeon’s presence.

At this point, I give the patient oxygen to breathe through a mask and I start the appropriate medications to induce anesthesia, taking into account any underlying health problems the patient may have, such as high blood pressure or heart problems. As the medications go into the IV, the patient stops breathing and I take control of the ventilation. Then I insert a special breathing tube into the airway. This tube, called a double-lumen tube, allows each of the patient’s lungs to be ventilated separately. The lung with the cancerous tumor needs to be collapsed and motionless while the surgeon operates on it. The other lung is ventilated. I have to position the tube precisely with a fiberoptic bronchoscope so that it functions properly — allowing full collapse of one lung and effective ventilation of the other, and making sure that the patient receives plenty of oxygen.

Once I’m happy with the position of the double-lumen tube, I may need to place other lines — perhaps a larger calibre IV, or an arterial line to measure the patient’s blood pressure continuously. The nurse may need to insert a urinary catheter.

When we’re done, we call for help to position the patient for surgery. This involves coordinating a team of operating room staff to turn the patient safely all the way onto one side, right or left depending on which lung needs surgery. We pad all the bony prominences — hips, knees, elbows — for comfort, putting pillows between the knees and positioning a padded axillary support to protect the nerves in the “down” arm. The nurse cleans the surgical site with antiseptic solution, and the surgical technician covers the rest of the patient’s body with sterile drapes. I recheck the breathing tube’s position with the fiberoptic bronchoscope.

Now we’re ready for the surgeon.

Team may work better with surgeon elsewhere

Surgeons remind me sometimes of racehorses. They are eager for the event to start, and impatient with anything that keeps them from bolting out of the starting gate and laying knife to skin. They’re perfectly willing to acknowledge that all the preparatory activities I’ve just detailed need to be done, and that the people doing them can’t be rushed too much or harm to the patient could result. But surgeons hate to stand around and watch — they pace, and mutter, and consciously or not, they put pressure on the OR team to move faster so the operation can start.

Everything goes more smoothly when the surgeon is happily occupied in the case next door. Experienced teams know how to stagger the starts so that the surgeon is in the key portion of the first case during the preparations for the second.

Once the critical work of the first case is complete, the surgeon can leave safely to begin work on the second one. The surgical technician and nurse begin the precise count of all the surgical instruments, needles, and sponges to make sure nothing is left inside the patient, while a surgical resident or fellow, or one of the surgeon’s partners, begins to close the wound. Once that’s done, members of the surgical team apply the dressing and reposition the patient for the wake-up from anesthesia. I make sure the patient is breathing well and all vital signs are stable, and then I remove the breathing tube. We move the patient from the OR table to the stretcher, and transfer the patient to the postanesthesia care unit. All these activities at the end of the case take time as well, and none of them requires the presence of the chief surgeon.

Often, the team is more efficient and at ease when the surgeon is occupied elsewhere while the patient wakes up and everything is done to move the patient safely out of the operating room. Then the operating room must be thoroughly scrubbed down before set-up can begin for the next case.

Better for shorter than longer cases

In most instances where I’ve seen surgeons running two operating rooms at once, safely and efficiently, the key surgical portions of the case are relatively short while the preparation time is long. A good example would be total joint replacements, especially hips and knees, where it takes time to set up complex equipment and place regional anesthetic blocks before the surgical team is ready for the surgeon.

What about long spine cases, such as those detailed in the Boston Globe article? Whether scheduling those cases concurrently is a good idea isn’t as clear cut. It would depend on the specific situation. In surgical groups where partners have comparable skill and experience, it often doesn’t matter much which surgeon is listed as the primary surgeon and which one is listed as the assistant. They may work together consistently, and when they run two rooms, the quality of care is no different. In fact, it may be better in the sense that they can each perform the parts of the work that they do best, and relieve each other for brief periods during especially long cases.

Should patients be told that surgeons have scheduled two operating rooms? Of course they should. And in my experience, they are. I’ve seen patients next to each other in the preoperative bays, chatting about the skill of their mutual surgeon and congratulating each other on their choice. They understand that the OR runs more efficiently when cases are staggered, and have confidence that each of them will have the surgeon’s full attention at the appropriate time.

It’s important to recognize, too, that no one can become an excellent physician without years of training. That training can’t happen just by watching. Residents and fellows need to perform surgery under supervision, just as anesthesia residents and fellows give anesthesia and do procedures under my supervision. As long as supervision is appropriate, a recent study has demonstrated that quality isn’t in jeopardy.

Reporters and the public shouldn’t rush to judgment about the wisdom of scheduling concurrent surgical cases. It’s important to understand how this long-standing practice may contribute positively to the overall performance and efficiency of the surgical team, and to the safety and well-being of our patients.


Bob Ruxin

Karen-- I shared this post with a good friend and her adult daughter who recently had complex surgery at MGH and is scheduled for another one in March. We had just discussed the article and I tried to argue there might be good reason for double booking. Your inside perspective makes the case much more persuasively. I suspect not only your medical, but your journalistic credentials trump those of the Globe reporters and editors.

John Beauregard MD

Well said Karen. I wish people who are not in the trenches would withhold their commentary on things they have limited knowledge of. A sign of true wisdom is the ability to reserve your commentary on things in which you have little true knowledge or at the very least provide a clear disclaimer stating that your opinion is based on your perception with little true knowledge. Of course that would betray the arrogance of the writer to portray himself as an expert ...Read More



I admit, I was taken aback at the headline in the Houston Press:


The curious reader is bound to wonder why the anesthesiologist would leave the operating room in the first place.

Of course, reporter Dianna Wray explains that in many hospitals, one physician anesthesiologist often supervises multiple cases staffed by nurse anesthetists. This model of care is called the “anesthesia care team“, and has a very long record of safe practice in nearly all major hospitals in the United States. Typically, the anesthesiologist makes rounds from one operating room to the next, checking on each case frequently, just as an internal medicine physician would round on patients in the hospital who are being monitored by their nurses.

Ms. Wray’s article narrates in detail what happened in several anesthesia cases where things went horribly wrong. She points out that the patients and families were not aware that the anesthesiologist would not be present during the entire case.

Complications can develop with patients on the ward, in the intensive care unit, or in the OR. In any medical setting, the nurse’s job is to recognize the problem in time to call for help, so that the physician can respond and the patient can be treated successfully. Sometimes, the call for help may not come in time for successful resuscitation. The results can be tragic — cardiac arrest, brain damage, even death. Hospitals track “Failure to Rescue” events that cause adverse patient outcomes as a Joint Commission and CMS standard for measuring quality in nursing care.

The fact is — anesthesia is dangerous. We have made huge strides in developing safer drugs and better monitoring techniques. But going under anesthesia — losing consciousness from the drugs we give — is really the same thing as inducing coma. Most anesthesia drugs have the potential to depress breathing, lower blood pressure, and decrease the function of the heart. Even regional anesthesia, using proven techniques such as spinal and epidural blocks, can cause major complications.

I can verify that even the most routine procedure — under sedation, regional block, or general anesthesia — has the potential to evolve into a crisis. Some days are completely routine, and some days I find I need every scrap of medical knowledge and experience I can bring to the problems my patients face.

No one should read Ms. Wray’s article and conclude that a physician anesthesiologist needs to be in the OR with every patient 100% of the time. Nurse anesthetists are highly qualified members of the anesthesia care team.

However, patients and families have a right to be informed about the plan of care. Will a physician anesthesiologist be present for the entire case, or supervising more than one case? Will a physician anesthesiologist be involved at all?  Many people would be surprised to learn that in a number of states, including California, there is no requirement for nurse anesthetists to be supervised by physicians, or even to consult with a physician about patient care.

Ms. Wray’s article explains that many nurse anesthetists feel that they should be able to practice in complete independence, without a physician anesthesiologist even on site. This is part of a concerted effort nationwide to grant independent practice to all advanced practice registered nurses (APRNs) — nurse practitioners, midwives, and anesthetists — in the name of cost-cutting.

Proposed changes to the VA Nursing Handbook would mandate that APRNs must practice in VA hospitals without physician supervision of any kind, whether or not the mandate conflicts with state law, and whether or not the nurse would prefer to have physician backup. Given how desperately ill and injured many of our veterans are, this seems like poor policy indeed.

The cases that Ms. Wray outlines in her article are tragic, and they prove how quickly a situation can deteriorate in the operating room. They highlight the folly of attempting to cut costs in our healthcare system by reducing the presence and availability of physicians. Once a patient has encountered a life-threatening complication, even the best attempts at resuscitation may fail. That’s why the key to success is having a high-functioning healthcare team that can avoid the complication in the first place.

To clarify one point in Ms. Wray’s article — certified anesthesiologist assistants, or CAAs, are qualified anesthesia practitioners on a par with nurse anesthetists. In the states where CAAs are licensed, they perform exactly the same functions in the operating room that nurse anesthetists do. The only major difference is that CAAs prefer to work under anesthesiologist supervision. Both CAAs and nurse anesthetists are certified healthcare practitioners who take direct care of patients, as distinct from anesthesia technicians who assist with anesthesia equipment and technical procedures.

I’ve written before about what a shame it is that animosity ever exists among healthcare professionals in any field, especially my own. Medicine is, or should be, a team sport. I rely on an entire surgical team of physicians, nurses, and technicians taking care of my patients every day. I’ll always value the wisdom, skill, and friendship of the many experienced nurse anesthetists I worked with at Duke University Medical Center when I was a young physician fresh out of residency.

My husband, a cardiac anesthesiologist, often gives his residents a favorite piece of advice:  “In anesthesia, it’s not necessarily what you know, it’s what you can think of in time.” Sometimes what you need to think of is to call for help. I’ve certainly done that on any number of occasions, when I needed someone with a different set of specialized anesthesia skills from my own, when I wanted to run an unusual problem by an experienced colleague, or when I just needed an extra pair of hands.

That’s the real advantage of the anesthesia care team. Help is around when you need it. You just need to think of it in time.



Dr. Sibert has a marvelous talent for translating "Medicaleeze" into "Everydaypeopleeze". Again herein proven. I hope she is planning to collect her writings into a book for "The Public". For the record: The status of CRNAs in the U. S. Armed Forces was accomplished by a series of command decisions by non-medical line officers. It was based on apparent cost, shortage of anesthesia physicians, and an inherent conflict between line officers and physicians of any specialty. There was never any consideration of the wisdom or a ...Read More


Dr. Silbert: Good post. But I disagree with some of the points made. 1) CAAs are not on par with CRNAs. With experience, a CAA, CRNA and anesthesiologists will all be on equal footing as stated by several anesthesiologists. But to state it as one surgeon placed its that someone with ZERO prior medical training/education can learn and understand all the complexities of physiology, pharmacology, and anesthesia in only 2years of training and are on the same footing as CRNAs is dishonest and hard to ...Read More


Compression fx PNG

It’s amazing how quickly my role switched from physician to patient, thanks to a silent assailant: osteoporosis.

I went to the gym in the morning before work 12 days ago, as I often do now that my children are all grown up and out of the house. First, a couple of light sets of leg exercises served as a warm-up, and then I started a set with a barbell on my shoulders. I’ve been doing weight training for years, since my mother suffered badly from osteoporosis and I knew I was at risk. Weight training, along with calcium and Vitamin D, can help maintain bone density.

The weight was average for me, and I was halfway through my second set of 12 repetitions when suddenly there was a loud noise, like a sharp crack or pop, that people in the gym heard 10 feet away. I felt my mid-spine collapse downward what seemed like an inch, accompanied by sharp pain. The trainer grabbed the weight, helped me lie down, and called my husband.

I did a quick self-assessment.

Can I move everything? Check.

Is anything numb? No.

Can I do a straight leg raise without more pain? Yes.

This confirmed that I didn’t have any spinal cord injury and probably didn’t have a herniated disk. The most likely diagnosis was a spinal compression fracture, which turned out to be exactly what happened.

Off to the emergency room

My husband insisted on driving immediately to the emergency room, which gave me a little time to reflect.

By coincidence, September is “Pain Awareness Month”, and I had been wanting to write a piece in support of the American Chronic Pain Association and the American Society of Anesthesiologists‘ recognition of pain as an endemic problem. Chronic pain ruins lives, and inappropriate treatment of pain with narcotics too often leads to addiction, overdose, and death.

But what to write?? I treat acute pain in my daily work as a physician anesthesiologist looking after patients in the immediate recovery timeframe, right after surgery. Sometimes I take Aleve for a headache, but that’s about it. Now, of course, it seemed much likelier that I would have a story to tell.

Luckily for me, the Cedars-Sinai Medical Center emergency room was relatively quiet at 6 a.m. The staff whisked me off to X-ray, and the technician quickly took supine and lateral films. He said, kindly, “Ma’am, I’m not a doctor, but it looks to me like you have a compression fracture.” He printed out the films for me to see, and of course he was right. A nurse gave me some morphine, which eased the pain considerably, and then it was time to consider next steps.

Conservative treatment or intervention?

My fracture was at the level of the 12th thoracic vertebra or “T12”, the commonest site for compression fractures. This is hardly a rare problem. One in four American women will have a vertebral compression fracture during her lifetime, and men can suffer them too. The most common cause is osteoporosis, a condition in which bone loss over time results in weak, brittle bones.

The emergency room physician ordered a CT scan to see the extent of the fracture in more precise detail, and to see whether or not any bone fragments were endangering the spinal cord. Then he called a neurosurgeon, Dr. Khawar Siddique, to see me.

The neurosurgeon outlined treatment options. Basically, there were three:

Conservative treatment: a back brace, pain medications, and 6-8 weeks of rest, with gradual mobilization;

Surgery: thoracic fusion;

Kyphoplasty: a less invasive procedure to stabilize the fractured vertebra.

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Dear Diana, Again, I think treatment choices are many, and should be decided by each individual in concert with your physician. As far as I am aware, estrogen therapy alone isn't enough to stop postmenopausal bone loss, but of course it may have multiple other symptomatic benefits. All best wishes, and thank you for writing-- Karen Sibert


Dear Dr. Sibert, What about estrogen therapy? And maybe even some testosterone therapy. btw, This is my first post ever on a blog. I feel so strongly about the benefits of estradiol therapy, in the form of brand Vivelle Dot patch, I had to respond to your story. Estrogen therapy may help prevent future fractures. I use Brand Vivelle Dot myself, for osteopenia. All the best to you during your recovery.

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Did it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague. When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working.

Or look at what it’s like to work in one of the world’s top restaurants. Edward Frame, now a graduate student in social research, described his first job in a Michelin-starred kitchen for an article in the New York Times.

“I worked in a small alcove, connected to the dishwasher,” he wrote. “Glass racks came out, I wiped away any watermarks or smudges, and then, just as I finished one rack, another appeared. This went on for hours, like some kind of Sisyphean fable revised for the hospitality industry. By hour two my fingers hurt and my back ached. But I couldn’t stop. The racks kept coming. Slowing down never occurred to me. There wasn’t time. I needed to make it nice. I wanted to make it nice.”

Let’s face it—a lot of people have jobs much worse than being a physician. Apparently, they don’t expect to be coddled or to receive much sympathy about their rate of burnout, or their lack of “work-life balance”. Nor do they expect that workplace expectations will be altered just to suit them.

I can’t imagine having the gall to complain about how tough it is to be a physician when all you have to do is open your eyes and see what’s all around us:  people working incredibly hard, making far less money than we do, and then returning home to face the responsibilities of family life, child care, housework, home maintenance, and everything else.

We—physicians—thankfully can afford help with these tasks. The Medscape Physician Compensation Report for 2015 reported that the average compensation for a primary care physician was $195,000 and for a specialist $284,000.

When I was a new faculty member making an instructor’s salary right after residency, it’s true that I didn’t have a lot of take-home pay left after I made monthly payments for student loans, private pre-school for two children, housecleaning help, and a full-time nanny to provide transportation and after-school care. The full-time nanny was essential because a child with a bad cold or an upset stomach needs to stay home, and a physician can’t drop everything to stay home too. These were investments that my husband and I made because we felt that being a physician is important work.

But in medicine, the prevailing wisdom today is that the rigorous culture of the past needs to change—along with the expectation of dedication to duty, long work hours, and stoicism—because it’s all just too difficult and we risk getting burned out.

Now Stanford University has started a new “time-banking” program designed to ease pressure on faculty physicians and basic science professors. As admiringly described by reporter Brigid Schulte in the Washington Post, the program allows faculty members to “bank” hours that they spend on uncompensated activities such as committee work and earn credits to use for support services at home or work.

Dr. Gregory Gilbert, an emergency physician who was the poster child for the Post article, used his credits for delivery of meals to his home, housecleaning services, and employing a “life coach” to help him “find better balance in his life”.

Wait just a minute. I’m sure that Dr. Gilbert is a good person—a divorced father trying to be a conscientious physician and spend time with his children. He must be a smart guy if he’s on the faculty at Stanford. Do you mean to tell me that Dr. Gilbert couldn’t figure out how to order food delivery and arrange for housecleaning before Stanford came up with this program?

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Dear Dr. Vercammen, "Burnout" is a colloquial and imprecise term which means different things to different people. Major depression is a clinical diagnosis, a very serious illness, and a threat to life; that is not and has never been my subject. I'm sure you know the difference. Confounding the two, as you do in your comment, is sensationalism. To imply that my opinions make me either responsible for or indifferent to physician suicide is not only unjustified, it skirts close to the edge of libel. Please--and I ...Read More

Chris Vercammen, MD

Dr. Sibert- As a current senior resident looking forward to my chief resident next year, I was profoundly disturbed by your article, in particular that it found its way into wider circulation via KevinMD. I would hate for any current resident, in any field, who is experiencing burnout to have read your piece. It represents a particular type of fantasy, retrograde approach to how physicians work and live. 1) Burnout is a real phenomenon. Having experienced it myself during my training, it is a profoundly troubling ...Read More

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Anesthesia Books2

This column ran first in the online magazine for medical students, “in-Training”

In case you were wondering — robots won’t replace anesthesiologists any time soon, regardless of what the Washington Post may have to say. There will definitely be a place for feedback and closed-loop technology applications in sedation and in general anesthesia, but for the foreseeable future we will still need humans.

I’ve been practicing anesthesiology for 30 years now, in the operating rooms of major hospitals. Since 1999 I’ve worked at Cedars-Sinai Medical Center, a large tertiary care private hospital in Los Angeles.

So what do I think today’s medical students should know about my field?

A “lifestyle” profession?

For starters, I have to laugh when I hear anesthesiology mentioned with dermatology and radiology as one of the “lifestyle” professions. Certainly there are outpatient surgery centers where the hours are predictable and there are no nights, weekends, or holidays on duty. The downside? You’re giving sedation for lumps, bumps, and endoscopies a lot of the time, which can be tedious. You may start to lose your skills in line placement, intubation, and emergency management.

Occasionally, though, if you work in an outpatient center, you’ll be asked to give anesthesia for inappropriately scheduled cases on patients who are really too high-risk to have surgery there. These patients slip through the cracks and there they are, in your preoperative area. Canceling the case costs everyone money and makes everyone unhappy. Yet if you proceed and something goes wrong, you can’t even get your hands on a unit of blood for transfusion. To me, working in an outpatient center is like working close to a real hospital but not close enough — a mixture of boredom and potential disaster.

The path I chose is to focus on high-risk inpatient cases. I especially enjoy thoracic surgery, with the challenges of complex patients and one-lung ventilation. You can bring me the sickest patient in the hospital setting — where I have all the monitoring techniques, resuscitation drugs, blood products, bronchoscopes, and anything else I might need — and I’ll be perfectly happy. The downside: a practice like mine tends to be stressful and tiring, and I never know the exact time that the day will end. Hospitals that offer Level I trauma and high-risk obstetric care are required to have anesthesiologists in house 24 hours a day, 365 days a year. There’s no perfect world.

What type of person is happy as an anesthesiologist?

Even though women comprised 47% of the US medical school graduates in 2014, only about 33% of the applicants for anesthesiology residency were women. I’d be interested to hear from all of you as to why fields such as pediatrics and ob-gyn tend to be so much more attractive to women, because I genuinely don’t understand it. But I do have a few thoughts as to the type of person who is happy or unhappy as an anesthesiologist.

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Asha Padmanabhan, M.D

Dr. Sibert, just found your article and thoroughly enjoyed it. There is a wealth of information in here for medical students considering a future in anesthesiology. The one point I would add for the future of anesthesiology is the disappearance of the small group private practice model which at least in my part of the country (South Florida) has completely given way to the large national groups.That might be something anyone going into anesthesiology should consider. There are advantages and disadvantages to being an employee of ...Read More
Great post here! I think lots of medical students trying to decide whether or not to specialize in anesthesiology should DEFINITELY read this - definitely goes into things a lot of others don't. Thanks so much for sharing this!