SPECIAL ARTICLE

Critical Role of the Surgeon–Anesthesiologist

Relationship for Patient Safety

Jeffrey B. Cooper, Ph.D.

ABSTRACT
Teamwork is now recognized as important for safe, high-quality perioperative care. The relationship in each surgeon–anesthe-
siologist dyad is perhaps the most critical element of overall team performance. A well-functioning relationship is conducive

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to safe, effective care. A dysfunctional relationship can promote unsafe conditions and contribute to an adverse outcome. Yet,
there is little research about this relationship, about what works well or not well, what can be done to optimize it. This article
explores functional and dysfunctional aspects of the relationship, identifies some negative stereotypes each profession has
of the other and calls for research to better characterize and understand how to improve working relationships. Suggestions
are given for what an ideal relationship might be and actions that surgeons and anesthesiologists can take to improve how
they work together. The goal is safer care for patients, and more joy and meaning in work for surgeons and anesthesiologists.
(Anesthesiology 2018; 129:402-5)

T EAMWORK among the members of the operat-

ing room team is one of the most critical elements in
perioperative patient safety. Yet, it may be that the greatest
end, I address the questions previously noted and suggest
actions to work toward making the relationship optimally
effective whenever this dyad is at work. The triad relation-
portion of the variance for the effect of team performance ship of surgeon–nurse–anesthesiologist and others are also
on outcomes and safety is associated with one dyad in the critical to ensure safety, effectiveness, and quality. Yet, the
team: the relationship between the surgeon and the anes- dynamic between the two physicians who sometimes share,
thesiologist. My hypothesis derives from personal observa- yield, or compete for leadership has a power to enable or
tion, informed by the work of Diana McLain-Smith, who thwart success that may transcend that of the other dyads or
has identified the relationship between dyads in teams as multiple, simultaneous interactions.
essential to their success or failure.1 If it is true that leader-
ship dyads are a or the key element in safety, quality and/or What Do We Know about the Surgeon–
effective function of operating room teams, then the dyad of Anesthesiologist Relationship?
the surgeon and the anesthesiologist is the dyad we should In this context, “relationship” is about how well two people
seek to understand and optimize. get along, how much they respect and trust each other and
I can find little research about this relationship in the lit- each other’s opinion, how much they rely on each other for
erature. How do anesthesiologists and surgeons view each advice, how likely they are to keep each other informed of
other? What do they expect of each other? Do their values actions impacting their dyadic partner. There is literature that
differ and if so, in what ways and how might that affect their speaks to some empirical aspects of the surgeon–anesthesiol-
ability to make the best decisions for a patient? How does ogist relationship.2–6 Communication and conflict have been
their effectiveness as a dyad in the larger team impact the examined and suggestions given for addressing both.
function of that team? When the going gets tough, what is Conflict in the operating room between individuals—
it about that relationship that will contribute to success or mostly between the anesthesiologist and surgeon—is a sig-
failure? And, if the relationship is critical to safety (patient nificant concern and has been experienced or witnessed by
and caregiver) and it is sometimes or often dysfunctional, almost everyone who works in an operating room. While
what can be done to improve its performance? conflict related to professional decisions is to be expected
I believe that greater understanding of the dynamics of and healthy if managed well, personal conflict is not healthy
the surgeon–anesthesiologist relationship will lead to inter- and never in the best interest of the patient. Due to the
ventions that will improve it and have the effect of increasing vagaries of work and of human beings, conflicts can arise
patient safety and the quality of perioperative care. To that even when there is a generally healthy relationship between

This article is being simultaneously published in the September 2018 issues of the Journal of the American College of Surgeons and
ANESTHESIOLOGY.
Submitted for publication March 14, 2018. Accepted for publication May 22, 2018. From the Department of Anesthesia, Critical Care and
Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2018; 129:402–5

Anesthesiology, V 129 • No 3 402 September 2018

Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
<zdoi;10.1097/ALN.0000000000002324>
 SPECIAL ARTICLE

the parties. Often it may be a visible and potentially Observation 4: Each side of the dyad sometimes attri-
destructive manifestation of a suboptimal or toxic relation- butes motivations to the other that are not solely in the best
ship. Whether the conflict is problematic depends on how interests of patients.
it arises and then how the individuals manage it. Too often, While I am not aware of empirical data to support the
that is not done well. following characterizations, I offer some examples of atti-
The duration of the surgeon–anesthesiologist relation- tudes I’ve gleaned about how each side of the dyad some-
ships is variable—sometimes the individuals have only just times perceives that the actions of the other may not be in
met; other times they have worked together for a long time. the best interest of the patient.
Familiarity sometimes provides shared trust that helps to
defuse conflict; other times it forms an entrenched dysfunc- Anesthesiologists’ Negative Perceptions of Surgeons
tional relationship and distrust. Some negative perceptions of surgeons by anesthesiologists

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Some aspects of communication, perceptions of roles, include: failure to be knowledgeable about “medical” or
differing mental models, the tone set for enabling speak- “anesthesia-related” (as opposed to surgical) issues; failure to
ing up, and related issues have been addressed in numer- perceive or acknowledge the extent of blood loss; consistent
ous studies, most notably by Lingard et al.,2,3 and also by underestimation of surgical time; failure to be forthcoming
others.6–9 In none of these articles is there an emphasis to patients and families about the likelihood of success and
on understanding of the roots of the surgeon–anesthesi- magnitude of difficulty in recovery after surgery; failure to
ologist dyad functionality and dysfunctionality or how to adequately consider patient health conditions and patient
improve it. desires; and discouraging speaking up by others about safety
Unfortunately, little is written about effective relation- concerns.
ships in health care, especially exemplars of good working
relationships, which are more likely to be common in some Surgeons’ Negative Perceptions of Anesthesiologists
settings than in others. There is reason to believe that these Some negative perceptions of anesthesiologists by surgeons
contribute greatly to quality, safety, and efficiency. include: more concerned with finishing their day on time
than serving their patients’ needs; unreasonable eagerness to
Personal Observations cancel a procedure based on unjustified concerns; unappre-
I was drawn to this topic by personal observations and con- ciative of the need to maintain schedule; unreasonably long
versations with anesthesiologists and surgeons over my many turnover times; distraction and inattention during surgery;
years in patient safety and quality. Since I’m not a physician failure to communicate important changes in vital signs to
and have not directly experienced the behaviors from one the entire team; failure to keep the team informed of the
“tribe” as a member of the other, perhaps my perspectives need for vasopressor support; lack of understanding of the
are flawed in some ways. (The term “tribe” can be used to patient–surgeon relationship; and unwillingness to change
describe the different professions in the operating room, anesthetic approach for the surgeon’s need to optimize surgi-
e.g., surgeon, nurse, anesthesiologist, surgical technician. cal technical considerations.
For insight about how tribal instincts and behaviors can be
destructive between tribes, and for society, see Junger10). Yet, Differing Values
Surgeons and anesthesiologists have different jobs that can lead
by being an observer of both without that inherent bias, per-
to different values and motivations for what they see as best for
haps I have a perspective that the members of either tribe
the patient. The tribe in which each was trained has evolved a
generally do not. Admittedly, most of my experiences have
set of values and beliefs that are consistent with what generally
been with anesthesiologists, yet I’ve had enough similar con-
has optimized its success over the years. Haidt deeply explores
versations with surgeons to notice patterns, concerns, and
how values in our societies are developed and how they affect
hypotheses.
the way we perceive the “other.”11 Like all tribes, the overall
Observation 1: When the dyad is highly functional, it
success of the group can lead to negative perceptions of other
greatly serves the interest of the patient; each can help and
groups. Thus, some dysfunction between two individuals from
“rescue” the other. And, a good working relationship creates
differing tribes is to be expected. Hope for improving dyad
a much more pleasant working environment (for all).
functionality for the interests of the patient comes from rec-
Observation 2: When the dyad is dysfunctional, it can—
ognition and acknowledgment of the differences and efforts to
and does—sometimes lead to harm and often creates an
resolve or accommodate them.
unpleasant, and sometime toxic, working environment.
Observation 3: Each side of the dyad has some percep-
tions of the other that are derogatory. If I were to ask each What Might an Ideal Relationship Look
what they think about the other specialty in general, the first Like?
response would include some statements that are compli- When I am the patient, I want my surgeon and anesthesiolo-
mentary. (Corollary: when acting together, both may share gist to work in complete harmony, putting aside their per-
common stereotypes of other physician tribes.) sonal needs for the sake of my safety and welfare. Surgeons

Anesthesiology 2018; 129:402-5 403 Jeffrey B. Cooper

Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 Surgeon–Anesthesiologist Relationship

and anesthesiologists should gain deeper understanding of an excellent example of embedded ethnography in the sur-
the demands and constraints on each other’s professional gical tribe.15 Replicating that with an emphasis on the sur-
goals for patients in general as well as for any specific patient. geon–anesthesiologist relationship, from both sides, could
This would happen far enough in advance to respect the time be illuminating on the questions I’ve posed. Another area
needed for addressing those concerns. (Ideally a day or more for exploration and awareness that might be fruitful is that
in advance, or perhaps a serious “huddle” before bringing of emotional intelligence. Emotional intelligence is increas-
the patient into the operating room. The immediate pre- ingly understood to be important for effective leadership and
surgery time out may be sufficient for some prosaic needs.) relationship management.16
Each would be open to and encouraging of hearing the per-
ceptions and opinions of the other, even when it seems to Discussion
encroach on their own area of expertise. That can happen

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merely from the encouragement of asking questions. Each What Can Be Done in the Meantime, before We Have More
would always start with an extension of the “basic assump- Evidence?
tion” (from simulation-based debriefing) about the other: “I If you are an anesthesiologist or surgeon and you think that
believe that you are intelligent, competent, trying your hard- what I am proposing is worth addressing to improve the expe-
est to do your best and seeking to improve, and acting in the rience of your patients and your joy and meaning in your pro-
best interest of this patient and the organization.”12 Where fessional work, what can you do given the absence of empirical
there is legitimate disagreement about what option to pur- evidence? I haven’t tested these suggestions except in situations
sue, the debate would center on what’s right for the patient, where I have recognized relational dysfunction in my own life
so I can’t say for sure they work for the surgeon–anesthesiolo-
not who is right.
gist dyad. A certain amount of common sense and experience
Examples of missing elements that might contribute to
from my many years as a manager and leader of individuals
optimal relationships is interdisciplinary morbidity and mor-
and teams suggests to me that the following ideas make sense:
tality or case review, and an effectively conducted huddle. I
have been involved with both unidisciplinary and interdis- 1. Ask a colleague in the other tribe what are his or her
ciplinary quality assurance committees at two hospitals over perceptions of the members of your tribe. Have a dia-
the years. Both have advantages and disadvantages. Overall, logue about the source of those perceptions. It’s likely
discussing/debriefing challenging cases or adverse outcomes best to do this over a casual meal or beverage rather than
as a team seems highly preferable. There are barriers to doing during a case over the “ether screen.”
that, e.g., differing work schedules, or the need to feel com- 2. Read some of the articles referenced here to learn more
fortable outside one’s own tribe to say things that may be about dyad conflict and intertribal attitudes.1–3,10
critical. Fortunately, such interprofessional debriefings seem 3. Organize a focus or discussion group including a few
to be increasing so we can hope this will be a positive influ- members from each tribe. A professional facilitator can
ence on the overall working relationship. aid the success of such efforts.
4. One topic for a focus group could be explicit designa-
What Kinds of Research Can Lead to Better tion of how leadership should be shared or designated
Understanding? in different situations.
5. Next time a situation arises that makes you feel that a
The investigations about relationships between periopera-
colleague from the other tribe is doing something that
tive team members have not addressed most of the questions
seems more in their own best interest rather than in the
I posed at the outset. Surveys, focus groups, observational
patient’s interest, be curious and metacognitive. Con-
studies, the critical incident method, or deep ethnography
sider what other explanations there might be. If you
all could be used to shed light on what are the issues that
can do it in a nonthreatening, nonaccusatory way, you
make the surgeon–anesthesiologist dyad highly functional or
can ask the person; however, being able to pull that off
highly dysfunctional. As did the critical incident studies our
with true curiosity and nuance isn’t easy. It’s a skill that
own team conducted in the 1970s, these would be first steps
requires training and practice.17
to defining the issues more clearly, and perhaps quantifying
6. If you are fortunate enough to work in a hospital that
how much of a contribution dysfunction and high function
has a simulation program with training of the full oper-
impact care.13,14 Case reports of examples of both func-
ating team, avail yourself of or create an opportunity to
tional and dysfunctional relationships, and especially more
participate.18
nuanced aspects of the relationships that can contribute to
suboptimal care, also would raise awareness of how behav- If the issues identified here resonate with sufficient strength
iors and attitudes can lead to the best of care or the worst of to enough surgeons and anesthesiologists, certainly there is a
care and anything in between. Lingard’s work is most nota- role that the American College of Surgeons and the Ameri-
ble; such research can be extended to other research teams can Society of Anesthesiologists can play in exploring the
and venues. Bosk’s seminal book, Forgive and Remember, is issues and working to achieve a more optimal state.

Anesthesiology 2018; 129:402-5 404 Jeffrey B. Cooper

Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 SPECIAL ARTICLE

Given space limitations, I have not covered all aspects of the masthead page at the beginning of this issue. ANESTHESIOLOGY’s
this topic that are relevant in understanding and optimizing articles are made freely accessible to all readers, for personal use
only, 6 months from the cover date of the issue.
the surgeon–anesthesiologist dyad performance, e.g., work-
ing in fixed versus changing teams; interactions among other References
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You may be a surgeon or anesthesiologist for whom none 36:728–34
of this is relevant and who is fortunate to only have strong 3. Lingard L, Regehr G, Espin S, Devito I, Whyte S, Buller D,
surgeon–anesthesiologist relationships. Nonetheless, I have Sadovy B, Rogers D, Reznick R: Perceptions of operating

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Correspondence Weinstock P, Dwyer K, Lipsitz SR, Peyre S, Pawlowski JB,
Muret-Wagstaff S, Gee D, Gordon JA, Cooper JB, Berry WR;
Address correspondence to Dr. Cooper: 290 Tappan St., Brookline, Harvard Surgical Safety Collaborative: Pilot testing of a model
Massachusetts 02445. jcooper@mgh.harvard.edu. Information on for insurer-driven, large-scale multicenter simulation training
purchasing reprints may be found at www.anesthesiology.org or on for operating room teams. Ann Surg 2014; 259:403–10

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