1. Keep a professional tone
   

   As a trainee, you may not yet appreciate the emotional weight of the moment for the patient, or how your words are being received. Humor can fall flat or even seem inappropriate, especially when followed by a discussion of risks like anaphylaxis or postoperative stroke. That emotional whiplash isn’t reassuring; rather, it’s unsettling. Your goal is to be a calm, competent, and grounding presence. I hear a lot of awkward jokes in pre-op. I recommend waiting until you have a few years behind you, then you can work your personality into the conversation.

   
   
2. Show that you know the patient
   

   Generic questions like “What is your name?” or “Do you have any medical problems?” suggest you haven’t reviewed the chart. Instead, start with: “I’ve reviewed your history, and I’d like to confirm a few things to make sure we’re planning the safest anesthetic for you.”

   
   

   Demonstrate that you’ve read their record and are applying it to your care. Rather than say, “Are you on any blood thinners?” to a patient with recent cardiac stents and dual antiplatelet therapy, instead say, “I see you’re on aspirin and clopidogrel, and your cardiologist advised stopping them on Sunday. Is that correct?” This signals to the patient that you’re informed, in the loop, and detail-oriented. Also, remember the preop nurse has likely completed a large portion of the groundwork: vitals, med reconciliation, and NPO confirmation. You can work with them, not around them.

   
   
3. Focus your review of systems
   

   Zero in on what matters. Ask about new or worsening cardiac symptoms (e.g., dyspnea on exertion, orthopnea, chest pain, or edema), and review exercise tolerance. Other organ systems that warrant a pre-op review of systems include GI (in particular, you are screening for delayed gastric emptying), hematologic (DVT symptoms in a patient with recent trauma), and pulmonary.

   
   
4. Know your limits
   

   Be honest about what you don’t know. Don’t try to answer questions about a nerve block you’ve never performed, and definitely don’t speculate about the surgical procedure itself. If you’re unsure or concerned about something, speak to your attending first before alarming the patient. For example, saying “If we do sedation you will probably aspirate and we’ll have to intubate” creates unnecessary anxiety and may require de-escalation later. You should only share risk/benefit information with the patient when you are sure of its accuracy.

   
   
5. Be alert to key medications
   

   Pay special attention to anticoagulants, seizure medications, opioids, Parkinson’s meds, SGLT-2 inhibitors, GLP-1 agonists, and antihypertensives.

   
   
6. Keep the social history practical
   

   Ask precise, nonjudgmental questions that directly address relevant anesthetic issues. Chronic use of illicit substances may increase MAC but not predictably, and not in a way that would significantly alter your plan. The main consideration for these drugs is postoperative withdrawal, which is most pronounced with alcohol. There is little evidence that cocaine use causes clinically significant perioperative myocardial ischemia, outside of acute intoxication. Your job is to be your patient’s trusted advocate, not to conduct a stressful moral audit.

The airway exam is just as important to evaluate through history as it is through physical findings. The Mallampati scoring system is one very small feature of the airway exam, one that is dwarfed by the more obvious, pressing issues that I have outlined in this section. It should also be noted that studies have demonstrated that neck circumference and thyromental distance are more strongly associated with difficult intubation than Mallampati.

Most of the following airway red flags can be identified without even laying eyes on the patient, and they should immediately raise your level of concern.