Anesthesiology demands not only medical knowledge and clinical acumen, but also mastery of processes and throughput. As much as we would like to spend your first few months focusing on the medical aspect alone, timeliness and efficiency are inextricable from the curriculum. This is a concept you will likely pick up on day one. Being a successful trainee means recognizing that your intellect is valued, but only in tandem with your ability to keep the system moving. If you can’t show up on time, see your patient, hang the antibiotics, or run a smooth anesthetic, your thoughtful questions about the latest pulmonary function tests (PFTs) will carry less weight. The OR cares equally about knowledge as it does about reliability, efficiency, and punctuality.

Healthcare systems ultimately prioritize two things above all else: financial stability and operational efficiency. These goals often stand in tension with the ideals of patient-centered care: safety, individualized attention, and clinical excellence. That tension is where we come in as anesthesiologists. Because we support the hospital’s most revenue-generating service—surgery—our professional duty to provide meticulous patient care will always clash with institutional pressures to move faster and do more. Our challenge is to protect the patient while aligning these competing goals.

Perioperative medicine is a multidisciplinary field focused on the assessment, optimization, and quality improvement of patients throughout the entire surgical journey. This domain is largely driven by anesthesiologists and continues to expand. It is critical to develop this perspective early and to keep it up. Your training program will ideally set you off on the path to becoming a perioperative medicine clinician, but all too often I see this being to atrophy once trainees get into the routine of the same few anesthetic techniques. Learn to see the thousand-foot view of the patient, not just the operation in front of you.

Anesthesia is a medical subspecialty. You are the patient’s doctor in the OR. This means understanding the natural disease course of the most common medical afflictions, such as congestive heart failure (CHF), coronary arterial disease (CAD), diabetes, and chronic obstructive pulmonary disease (COPD). Mastery of these fundamentals is essential not only for your growth as a clinician but for the continued relevance and survival of our specialty. As a trainee, resist the impulse to lean on external consults to piece together your perioperative plan. While surgeons and proceduralists may call on other specialties to justify moving forward with a case, you are ultimately responsible for the patient’s medical optimization.

Before surgery, use your knowledge to act as a bridge between “silos” of care, whatever those may be: surgery clinic, preop, emergency room, ICU, imaging suite, trauma bay, and operating room. For example, if your patient is going to the OR for source control of a septic joint, you are responsible for ensuring that their antibiotic order started in the ER is continued throughout the perioperative phase. You are responsible for seeing that they are on methadone twice daily, and that this should be verified with the patient and continued without interruption to reduce perioperative withdrawal.

It’s important to maintain and grow your knowledge throughout residency and into your career, not just during your training years. If the last day of your training is the last time you open a book, your clinical relevance will be frozen in time. Without continuous learning, you risk becoming a liability to the teams you join and the patients you serve.

Keeping up with the literature is an extremely easy habit. Read about your patient and look up things you are not familiar with. Keeping up with major journals is easy by subscribing to their monthly table of contents. In the era of large language models such as OpenEvidence, you can simply type “summarize the table of contents of the latest issue of JAMA” or “summarize the latest evidence for aprepitant in preventing postoperative nausea vomiting.” Anesthesiology, A&A, CHEST, etc., as well as major medical journals like Journal of the American Medical Association (JAMA) and New England Journal of Medicine (NEJM) are useful to clue you into the major breakthroughs and medical cultural shifts of the time.

Reading about your patients isn’t just essential for delivering quality care (and yes, it’s very obvious when you haven’t); it also immerses you in a wealth of information about chronic diseases and their management.

A personal anecdote: In the early stages of training, mental and physical fatigue made reading feel overwhelming. I struggled with this myself during my CA-1 year, but a low ITE score in my first quarter was the wake-up call I needed to revisit my habits. I carved out dedicated time every night to read and spent just two or three evenings a week with reading material. I found it helpful to use my cases the next day as a template to decide what ITE topics to focus on. I also found that this mental preparation helped me be less anxious at work.

Your patient’s chart is a window into a myriad of learning opportunities. For example, you might read about the patient’s dens fracture and query its anesthetic implications. An ophthalmology note may describe narrow-angle glaucoma, and you can use this as an opportunity to learn about the anesthetic implications of various glaucoma therapies. Each clinical syndrome is a window into an entirely unfamiliar area of medicine. Try to read normal echocardiograms as well as abnormal ones, getting used to the common ranges of various indices such as left ventricle end-diastolic volume, etc. This allows you to be an informed consumer of a test you will read a million times over. In doing so, you can grade your patients on a spectrum that is more than just “the echo was fine” or “the EF was low.”

Take, for example, a patient presenting for a colectomy with heart failure. In an aspirational scenario, you understand her specific subtype of heart failure (systolic vs diastolic) and its underlying etiology, be it ischemic, rheumatic, restrictive, or amyloid related. You know her current level of exercise tolerance and are up to date on recent evaluations, including cardiac catheterization, echocardiography, and stress testing. You’ve reviewed the 2024 American Heart Association (AHA) guidelines and determined that she is appropriately optimized. You’re familiar with the components of Guideline-Directed Medical Therapy (GDMT) and their perioperative implications.

You’ve reviewed her physical exam and imaging to assess for signs of volume overload. Drawing on your cardiac rotation experience, you recognize key symptoms that could point to decompensated heart failure in the perioperative setting—cold extremities, altered mental status, oliguria, acidosis, and hypotension. You also have a working understanding of how inotropes differ from pressors, including which receptors each class targets.

You might think your attending wants a step-by-step list of drugs and IV sizes. Wrong! What they actually want is to see that you have a solid foundation of clinical knowledge and an awareness of potential complications. You can’t manage what you don’t understand. That starts with mastering the basics of clinical medicine.

The ability to adapt to unexpected clinical circumstances is our most specialty-distinguishing feature. The challenge of anesthesiology training is learning how to adapt to scenarios that require balancing conflicting goals, complications, and clinical extremes. This is your value proposition to the healthcare system.

Your treatment plan must take into consideration changes in location, transport, surgical conditions, and time constraints. A patient with diabetic ketoacidosis (DKA) presenting for open reduction of a hip fracture after being found down at home is a far more complex challenge than one with DKA already optimized on the medical ward. In the former, you’re tasked with simultaneously managing their DKA, providing safe anesthesia, and investigating the underlying cause of their “found down” status: whether it’s a coronary event, stroke, infection, or another acute process.

There are limits to our adaptability, and these limits are largely intuitive.

Table 5.1 highlights a few scenarios where our adaptability has boundaries. Our patients depend on your ability to draw these lines. Our patients rely on your judgment here. I’ve noticed that frustration often arises when trainees lean too far in either direction: some become overly accommodating to surgical requests, while others are rigid to the point of impeding care. Both of these scenarios are easy to avoid. When in doubt, especially when you’re being asked to adjust your plan, it’s always wise to check in with your supervisor.

You’ll learn over time which rules have flexibility and which lines must never be crossed. Early in your training, stay especially alert to situations that push you outside your comfort zone, particularly when plans change on the fly.

For example, it can be frustrating to hear that a trainee gave “a little bit of paralysis” during a laryngeal mask airway (LMA) case simply because the surgeon asked. While this might be a reasonable adjustment in some cases, it’s still an off-label move that warrants discussion and approval beforehand.

Another example: a common occurrence during your first year will be managing hypoxemia during laparoscopic surgery, particularly in a steep Trendelenburg position. I see residents frequently jump immediately toward asking to reduce insufflation pressures, confident that this is the only technique available. In reality, most of the time, the issue can be resolved with basic maneuvers: increasing positive end-expiratory pressure (PEEP), alveolar recruitment maneuver, and checking to ensure the tube is not mainstemmed. We can also tolerate some degree of ventilatory restriction. When the issue occurs, assume first that you can do something to optimize the patient, and ask for help from your attending. Managerial overconfidence is not a core skill for any anesthesiologist, much less a trainee.