Chapter 10
Synthesize, Prioritize, Execute

Reviewing and discussing your cases the night before serves multiple important purposes:

For you, it’s an opportunity to educate yourself about the patient, the procedure, and how to deliver a safe and thoughtful anesthetic;
For your attending, it’s a chance to gauge your clinical reasoning and situational awareness, especially critical for managing multiple rooms or high-acuity patients;
For the patient, it helps identify and address any last-minute issues that could delay or compromise the safety of the procedure.

The “RIME” framework is highly applicable to anesthesiology training. In this framework, learners progress through a spectrum of reporter → interpreter → manager → educator. At this stage in your training, with a great deal of foundational clinical experience behind you, you have ideally evolved well past the role of reporter and are stepping into the roles of interpreter and manager.

This means that rather than simply repeating information in the chart, your anesthetic plan should follow a coherent clinical narrative.

Instead of presenting your supervising attending with a laundry list of clinical problems in text message format, focus on synthesizing the information into a meaningful clinical story. Avoid open-ended questions (“What should we do about the epidural?”) and aim to answer them yourself first. Demonstrating initiative and showing ownership of the case will not only build your confidence, but it will also earn your attending’s trust.

A laundry-list style text is not wrong; it is just not particularly helpful to anyone to rewrite what is visible in the EMR. Think “what does my attending need to know?” or “what is likely to change our anesthetic plan?” Everyone has degenerative joint disease. But does this patient have significant cervical spine disease that could affect airway management? Coronary artery disease is common: but does your patient have stable angina? Stents? Exercise tolerance? The key is not just to present facts but rather to show what you’ve thought about their implications. That’s how you move from being a data collector to a critical thinker.

Consider the following examples:

Reporter: “Her creatinine is 1.9.”
Interpreter: “She has chronic kidney disease, likely secondary to diabetes and hypertension.”
Manager: “Given her CKD, she’s at increased risk for perioperative AKI. Her creatinine is at baseline, and she’s followed by nephrology, so I think it’s reasonable to proceed. I’ll ensure she’s well-hydrated preoperatively and avoid nephrotoxic agents like ketorolac.”
Educator: “I’ll also reach out to the PACU and surgical team to monitor urine output closely post-op and consider using the NephroCheck assay on postoperative day one.”

Remember, the goal of formulating an anesthetic plan isn’t simply to recite a list of drugs, doses, and timings. It’s to demonstrate that you understand the patient, anticipate physiologic challenges, and can articulate a thoughtful approach to each phase of the anesthetic.

Compare these two examples:

Low-level plan: “My plan is to give midazolam, then lidocaine, then propofol. Is that okay? Do you know if they want an epidural?”
High-level plan: “Given her age and the hypovolemia from her bowel obstruction, I think she’s at higher risk for hypotension on induction. I will plan on supplementing with phenylephrine up front. For analgesia, I think an epidural would be beneficial and I will reach out to the surgical team to communicate this.”

The high-level version reflects critical thinking, patient-specific tailoring, and awareness of both the physiology and the broader perioperative context. You’re not just outlining what you’ll do, but why.

You will frequently hear that in anesthesia, it’s not about the drugs you choose, but how you use them. This requires context: the patient’s physiology, surgical plan, and overall risk profile.

Since our communication style can sometimes be overly technical, I sometimes tell residents to consider how residents of other specialties speak with their attendings. For example, consider how a surgical trainee speaks to their attending. They’re unlikely to say: “First, I’ll bring the patient into the OR, have them lie down, and fasten their arms with the straps, let me know how you prefer to have them fastened. Then I’ll prep with chlorhexidine 2%—or do you prefer iodine?” Instead, they’re more likely to focus on the key elements of the operation: anatomical challenges, comorbidities that introduce increased risk, and an overarching surgical approach to the case.

You should approach your anesthetic plan the same way. Move beyond listing steps or drug sequences. Think critically about the physiology, the procedure, and the patient’s unique vulnerabilities.

Beyond the Cocktail: Thinking Critically About Drug Choices

Anesthesia is more than just a sequence of anesthetic agents. There is a tendency for trainees to come up with overly simplistic pharmacologic solutions to complex physiologic issues: “She’s tachycardic at baseline so I will use dexmedetomidine instead of ketamine.” I see trainees frequently get lost in this mindset, which confuses a perioperative challenge (pain management) with a pharmacologic side effect profile. Most of the challenges we face cannot be addressed with drugs alone. Instead, use each case as an opportunity to think more deeply about physiology, surgical context, and patient-specific factors. Developing clinical judgment rather than just memorizing pharmacology.

For the patient with tachycardia: why is she tachycardic? Is she very young? Hyperthyroidism? Hypovolemia from GI losses? Without that insight, the plan is superficial.

Take another example. “We’ll use phenylephrine instead of norepinephrine because of her atrial fibrillation.” This may reflect a basic understanding that norepinephrine has some chronotropy, while phenylephrine can cause reflex bradycardia, but it lacks depth. I’d rather hear you explain the pharmacodynamics of the two agents, and how each one might interact with the patient’s current rhythm, preload sensitivity, or risk of rapid ventricular response. Shorthand reasoning like “phenylephrine = low HR, norepinephrine = high HR” misses the point.

Example: Weak vs. Strong Case Presentation

You are presented with a patient who needs an urgent hip fracture repair after a fall. Your plan regarding her cognitive state, which is a complex perioperative issue:

“I’ll avoid midazolam.”

End of story. There is some clinical insight here, yes, but it is very meek. I would rather you tell me specifically about postoperative cognitive decline and how we can prevent it.

“I’m concerned about her baseline frailty, dementia, and likelihood to experience severe side effects from opioids. I’ll plan to place an epidural for surgical levels of anesthesia to avoid GA, encourage early ambulation, maintain intraoperative MAP within 20% of baseline, and avoid unnecessarily deep sedation.”

That kind of thinking shows maturity and real clinical insight. Applying pharmacology intelligently, in the context of the patient’s physiology, risks, and goals, is what defines a great anesthesiologist.

Consider another patient, this time with pulmonary hypertension. Here’s an example of a low-level plan:

“I was thinking to give 3 mL of 2% lidocaine, 1 mg/kg of propofol, 50 mg of rocuronium, and 75 mcg of fentanyl. We’ll have to be careful with her blood pressure. How do you usually do these cases?”

While technically accurate, this plan focuses on the drugs rather than the physiology and doesn’t demonstrate a clear understanding of the anesthetic implications of pulmonary hypertension.

Now consider a high-level plan:

“My primary goals for induction are to prevent even transient hypotension and avoid hypoxemia. I plan to place a pre-induction arterial line and start a phenylephrine infusion before induction. I’ll titrate the induction agents carefully and supplement with pressors as needed. To minimize extubation risk, we’ll have advanced airway equipment ready, and I’ll ensure she’s fully awake, strong, and oxygenating well before extubation. Throughout the case, I’ll aim to keep the MAP in the 80s to support right heart perfusion and avoid right ventricular strain.”

This version reflects an understanding of the underlying pathophysiology, identifies key risks, and outlines a thoughtful, proactive plan for both induction and emergence. It’s not just about the drugs! It’s about using them in the service of clearly defined clinical goals.

Here is an example of a full presentation from a reporter-level learner:

“Our first case is a 65-year-old with hypertension, hyperlipidemia, asthma, CAD, anxiety, depression, who presented in March with shortness of breath. She got a chest X-ray showing a 2.3 × 1.2 cm nodule. They recommended a chest CT, which she had a few months later. That showed bilateral ground-glass opacities, a new left upper lobe nodule, and mild bilateral pleural effusions. She had a lung biopsy and was admitted overnight. I’m not sure why. Her sodium is 128. I’m also not sure why.

My plan is standard monitors, 2 mg of midazolam because she has anxiety. I’ll decide once I meet her. I think we should intubate with a double lumen tube, but I wanted to ask which size you prefer? Do the surgeons care? Also, could we try a bronchial blocker since I haven’t used one before? Oh, and maybe we could do a serratus block?”

What’s missing here? The reporter has not synthesized information, has not delved into the etiology of her lab abnormalities, has an unfocused plan with too many questions posed to their supervisor, and has no sense of priority.

Here is an example of a more evolved, interpreter-level presentation:

“Our first case is a 65-year-old woman with newly diagnosed left upper lobe lung cancer, scheduled for a lobectomy. Her history includes CAD with stents placed 10 years ago; she reports good exercise tolerance and no cardiac symptoms.

Her labs are stable aside from a sodium of 128, which appears chronic and asymptomatic. This is likely SIADH related to her cancer or immunotherapy.

My plan is general anesthesia with a 35 Fr left-sided double lumen tube for lung isolation and a postoperative serratus block for analgesia. I don’t have any specific intraoperative concerns. I am looking to improve my technique in one-lung ventilation and would appreciate any tips you might have.”

This is better, because it prioritizes relevant information, synthesizes history rather than listing it, offers a clear, coherent anesthetic plan, anticipates potential concerns, and demonstrates critical thinking.

When you present cases, aim to summarize, synthesize, and propose. Via text or phone call, your attending should be able to quickly understand:

Who the patient is
What matters most about their history
What your anesthetic plan is, and what your concerns are

Seasoned anesthesiologists seem like a relaxed bunch, but they respect accuracy and precision. No one is impressed by a casual, off-the-cuff presentation from a trainee. While I appreciate the temptation to show you are confident and laid back, you should err on the side of professionalism, at least in your first year. Trust me, it will work!