Volume 12, No. 3 • Fall 1997

APSF-Sponsored Research Probes Resident Attitudes about Patient Safety

J. M. Healzer, M.D.; S.K. Howard, M.D.; D.M. Gaba, M.D.

An extensive questionnaire survey and subsequent analysis concerning the attitudes and practices of anesthesiology residents in American training programs was conducted by a Stanford University team led by David Gaba, M.D., a member of the APSF Executive Committee. The projects, funded by a research grant from the APSF, involved co-investigators J.M. Healzer, M.D. and S.K. Howard, M.D. A capsule review of the findings and an analysis will appear in the Winter issue of the APSF Newsletter.

In the meantime, one component of this research will be presented in an abstract at the ASA Annual Meeting. “Sleep and Work Schedules of Anesthesia Residents: A National Survey” is Abstract Number 932 and will be seen as part of a poster session Monday, October 20, 9-11 a.m.

In addition, to illustrate the extensive nature and piercing relevance of this body of work, a survey summary of one other aspect of these findings is presented here. Great discussion of the potential negative impact of “production pressure” on anesthesia patient safety has taken place in the recent period of intense emphasis on cost-cutting and efficiency in medical care delivery, particularly the functioning of operating suites and associated anesthesia services. The sometimes maniacal drive to “do more with less” and “go faster, no matter what the risk” in operating rooms today is perceived by some as a direct threat to patient safety. Anesthesia residents were polled on this subject:

Attitudes Toward Production Pressure and Patient Safety: A Survey of Anesthesia Residents

A prior survey has examined the attitudes of practicing anesthesiologists toward “production pressure” or the economic and social influences on anesthesiologists to place production, not safety, as their primary priority. Little is known about the attitudes of anesthesia residents toward production pressure and patient safety issues they face during residency training. This survey was designed to investigate how anesthesia residents are affected by production pressure.


Multiple survey packets each consisting of a survey and a postage paid return envelope, were mailed to program directors of all accredited U.S. anesthesia residency programs. Program directors were requested to distribute the survey packets to their residents. The number of survey packets sent to each residency program was determined by the number of enrolled residents reported by the program to the ABA in July 1995. Respondents answered questions regarding their attitudes toward production pressure and patient safety issues on a Likert scale of 1 (strongly disagree) to 5 (strongly agree). Data were presented as percent of respondents who either disagree (1 or 2) or agreed (4 or 5) with a specific question. Respondents also answered questions regarding how often during residency they had witnessed patients being anesthetized under sub-optimal conditions on a Likert scale of 1 (never) to 5 (very frequently). Data are presented as percent of respondents who had witnessed such events (2-5).


Of 4744 residents in U.S. anesthesia residency programs in July 1995, 734 surveys were received (15.4% response rate). Respondent demographics (gender and year of training) were similar to the demographics of residents in U.S. anesthesia residency programs. 1. Surgeons do not understand the risks of anesthesia. (76% agree) 2. My workload on call is heavy. (63% agree) 3. I rarely feel fatigued at work. (75% disagree) 4. I have postponed a case because the patient had not undergone adequate preoperative evaluation. (66% agree) 5. I have never witnessed a surgeon do something that appeared to me to be unsafe. (80% disagree) 6. I have witnessed my attending do something that appeared to me to be unsafe. (59% agree) 7. I receive less supervision at night or on weekends than during regular working hours. (52% agree) 8. I have performed invasive procedures or fiberoptic intubation on patients solely for teaching purposes. (16% agree)

On at least one occasion during their anesthesia residency the following fractions of respondents have witnessed patients anesthetized for elective surgery in the following sub-optimal conditions: without sufficient medical or surgical evaluation (94%) with significant contraindications to surgery or anesthesia (69%) and without adequate monitoring or venous access (72%). Production pressure also resulted in intraoperative management problems: failure to call for help in a major crisis to avoid “looking bad” (37%); and non-emergent cases not aborted after a catastrophe such as cardiac arrest (39%).


Although the low rate of response to this survey suggests a risk of selection bias, it is clear that anesthesia resident respondents are affected by pressure to place production, instead of safety, as their primary priority. These pressures are similar to those found to affect practicing anesthesiologists in an earlier survey. While the effects of production pressure on patient outcome is unclear, the survey results suggest that in some cases, patient safety is significantly compromised. Additional studies are needed to further define the effects of production pressure on anesthesia residents and to examine the effects of production pressure on patient safety.


1. Gaba D, Howard SK, Jump B. Production pressure in the work environment: California anesthesiologists’ attitudes and experiences. Anesthesiology 1991;81:488-500

Be sure to look for the overall survey summary in the Winter issue of this newsletter.