Surgeon-Anesthesiologist Disagreements About Emergency Surgery Urgency
Yes, surgeons and anesthesiologists frequently have substantial disagreements about the importance and urgency of emergency surgical procedures, with documented discord in approximately 30% of critical team exchanges in the operating room. 1
Evidence of Communication Breakdown
The most direct evidence comes from emergency surgery guidelines, which explicitly state that failure to communicate critical information in the operating room occurs in approximately 30% of team exchanges between surgeons and anesthesiologists. 1 This communication failure can lead to:
- Inefficiency and delays in patient care 1
- Emotional tension between team members 1
- Resource waste 1
- Procedural errors that can be detrimental to patient outcomes 1
Specific Areas of Disagreement
Divergent Professional Perspectives
A multiple-choice survey of New York metropolitan area anesthesiologists, surgeons, and cardiologists revealed substantial disagreement on the importance and purposes of consultations, with key areas of discord including: 1
- Intraoperative monitoring: Regarded as important by most surgeons but unimportant by anesthesiologists 1
- "Clearing the patient for surgery": Considered important by surgeons but not by anesthesiologists 1
- Advising on the safest type of anesthesia: Valued differently between the two specialties 1
Critical Information Gaps
Failure by the anesthesiologist to communicate critical information during resuscitation of critically ill patients—such as impairment of metabolic parameters or improvement achieved by goal-directed resuscitation—may leave the surgeon unaware of the degree of patient physiologic exhaustion, leading to wrong surgical decisions. 1 This represents a particularly dangerous form of disagreement where each specialty possesses critical information the other needs but fails to share it effectively.
Impact on Emergency Decision-Making
Time-Sensitive Scenarios
In acute surgical emergencies, preoperative evaluation might have to be limited to simple and critical tests (rapid cardiovascular assessment, volume status, hematocrit, electrolytes, renal function, urinalysis, and ECG), with only the most essential interventions appropriate until the emergency is resolved. 1 This compressed timeline amplifies potential disagreements about:
- Whether resuscitation is adequate to proceed 1
- The true urgency classification of the case 1
- Risk-benefit calculations for immediate versus delayed surgery 1
Hemodynamic Assessment Disputes
Hemodynamic stability or instability after adequate resuscitative maneuvers remains the main tool to risk-stratify patients for immediate surgery or not. 1 However, what constitutes "adequate resuscitation" is a common point of contention, as the anesthesiologist may assess physiologic parameters differently than the surgeon assesses surgical urgency. 1
Structural Factors Contributing to Disagreement
Different Risk Assessment Frameworks
Surgeons and anesthesiologists use different frameworks to evaluate the same patient:
- Surgeons focus on the TACS (Timing of Acute Care Surgery) classification system, which prioritizes hemodynamic status and surgical disease severity 1
- Anesthesiologists emphasize ASA physical status classification, which assesses systemic disease burden and perioperative risk 1, 2
These parallel but non-identical systems can lead to conflicting conclusions about surgical timing.
Experience and Seniority Gaps
Surgery led by trainee surgeons is independently associated with increased intra- and postoperative events, and the presence of both a senior surgeon and senior anesthesiologist in the operating room is associated with improved outcomes. 1 When experience levels are mismatched, disagreements about urgency and approach are more likely.
Clinical Consequences of Poor Communication
The World Society of Emergency Surgery emphasizes that effective and prompt communication allow the anesthesiologist and surgeon to recognize potential issues or dangerous circumstances and adjust their strategies accordingly, particularly when considering damage control approaches in critically ill surgical patients. 1
A close intraoperative communication between surgeon and anesthesiologist is essential to assess the effectiveness of resuscitation, in order to decide the best treatment option (Level of Evidence 2, Grade of Recommendation C). 1
Common Pitfalls
- Assuming the other specialty shares your urgency assessment: Each specialty views urgency through a different lens—surgical pathology versus physiologic reserve 1
- Failing to explicitly communicate metabolic and hemodynamic parameters: The anesthesiologist must actively share resuscitation effectiveness data, not assume the surgeon is aware 1
- Proceeding without consensus in non-life-threatening cases: For TACS Class 3 and 4 cases (urgent but not immediately life-threatening), taking time to align perspectives improves outcomes 1
- Relying on consultations that provide no actionable recommendations: 40% of cardiology consultations contain no recommendations beyond "proceed with case" or "cleared for surgery," which fails to address the anesthesiologist's concerns 1
Optimizing the Relationship
Research on surgeon-anesthesiologist relationships identifies this dyad as perhaps the most critical element of overall team performance, with a well-functioning relationship conducive to safe, effective care and a dysfunctional relationship promoting unsafe conditions. 3
Effective communication and expression of non-technical skills among anesthesiologists, nurses, and surgeons are essential to manage critically ill emergency surgical patients. 1 This requires:
- Explicit discussion of resuscitation endpoints before proceeding 1
- Shared mental models of what constitutes "adequate" preparation 4
- Recognition that emergency surgery requires frequent and open communication between all healthcare providers, the patient, and family 4
- Understanding that the aggressiveness of surgical intervention is patient- and disease-specific 4