On a Monday morning in March, an anaesthetist stood outside his children's inner Sydney school as a solitary protestor, asking parents to keep their children home if they could.

In the heady early days of the coronavirus pandemic, alarm was raised by a disparate mix of professionals: virologists and epidemiologists, journalists and technologists, and a range of frontline and critical care medical specialists exposed to the first COVID patients.

But as concern spread from the earliest hit countries to those threatened by their own surge, one specialty group was over-represented in public calls for early action: anaesthesia.

In Australia, medical anaesthetists from all states and territories spoke-up, not for health authorities and legislators, but for their communities. For a specialty most comfortable when not spoken of, suddenly anaesthetists were appearing in national newspapers, on radio, television, and even (very small) picket lines.

In Victoria, Dr Pieter Peach was a prominent early voice pushing for cancellation of Melbourne's Grand Prix. The Australian Society of Anaesthetist's fearless president Dr Suzi Nou guided the society's careful campaigns to prepare for the pandemic, pause elective surgery and then cautiously restart. In NSW, Dr Tanya Selak's advocacy was celebrated on Telstra's #saythanks billboard, while Rob picketed outside his children's school.

Like a warning telegram from 1940s London, the message scrawled on Rob's chest captured the zeitgeist of our specialty at the time:

"Lives depend on it. Government too slow to act."

More anaesthetists added their voices, like Dr Cameron Graydon in Queensland, and WA AMA President Dr Andrew Miller, who cut straight through the noise to call a spade a f%$king shovel to the appreciation of the Western Australian public. Plus many, many more of us working publicly or behind the scenes.

What was it about anaesthetists and anaesthesiologists1 that made for such vocal Cassandras? Was it simply panic built upon our fear of personal risk? A plugged-in critical care community watching stories from Italian anaesthetists in horror? And then the same from London… and New York…?

While these played a part, more importanty there are unique cultural and cognitive features of anaesthesia and anaesthetists that motivated many to give voice to the risk. Some of these also appear in sibling critical care specialties, among emergency medicine and intensive care specialists – but not in the same ways, and diluted by their own tribe's characteristics.

Anaesthesia culture

Culturally anaesthesia is typified by strong group cohesion, teamwork, bias toward collaboration and in-group trust – and yet mistrust of institutional authority. Ironically Australia's outgoing Chief Health Officer, Mr Covid himself, learnt this the hard way in his earlier life as CEO of Austin Health.2

It is probably the simmering mistrust of authority mixed with our quiet subversive streak that motivated anaesthetists to speak out once the pandemic risk was internalised. Although many anaesthetists actually have additional Master's degrees in Public Health, Biostatistics and even Epidemiology (we're an over-educated bunch; there are quite a few PhD's out there too...) as pandemic-expert-adjacent we do not carry the same reputational risk as fully-fledged epidemiologists, public health or infectious disease specialists that might have otherwise tempered our loud advocacy.

Broadly, we are always up for epistemic trespass.

Anaesthesia cognition

But why did anaesthetists so quickly identify the growing risk even before the WHO declared a pandemic?

Anaesthetists have an intuitive understanding of Bayesian probability, asymmetric risk3, systems thinking, and contrary to stereotypes, profound risk aversion. Anaesthetists know risk.

I don't mean "hey bro, we understand risk", I mean we really know risk. We feel risk. The way an experienced pilot feels the plane as she flies. The way Neo sees the matrix.

Each day anaesthetists balance the competing risks of hundreds of decisions, big and small. Factoring in patient wishes, surgical needs, priors and specific situations. We are obsessively proactive, understanding the lag between intervention and effect, carefully adjusting the now to avoid small diversions that may multiply later into bigger, badder outcomes.

We allow for black box decision making, knowing that our understanding of human physiology is only a simplified model that helps navigate how someone behaves before, during and after anaesthesia. Many steps of our decision making are guided by necessarily-imperfect models.

Anaesthetists understand that responses are time critical – we are specialists of dynamic decision making. We know that acting early with incomplete information is often better than acting too late with perfect information. We are biased to act and intervene, perhaps to a failing, rather than to watch and wait.

These traits are common to many anaesthetists, whether the specialty selects the type A personalities that typify our craft, or we become this way as we train, encultured into the behaviour.

Asymmetric risk and the pandemic

Whether nature or nurture, anaesthetists immediately understood the asymmetric risk of the SARS-CoV-2 pandemic with it's almost uncapped downside, but manageable upside. We were wise to the reality of exponential growth, sigmoid curves and the lag time for exposure, illness, hospitalisation and death. Anaesthetists were very comfortable with the uncertainty of incomplete case information, but could see the rough probability tree of outcomes. Many of these were very bad, enough were apocalyptical.

Anaesthesia has a long history of driving patient safety improvements4, both because of our daily risk consumption, and also because culturally we see ourselves as patient advocates. For many anaesthetists it was only a small extra step to go from advocating for patient safety in hospitals, to the shared safety of the wider community.

Most importantly we saw the need to act early – the disproportionately greater benefit but lower cost of early intervention versus waiting. When WHO pandemic experts extolled the need to "go hard and go early" it felt immediately familiar.

Finally, threaten anaesthetists with conscription to intensive care units and we will move heaven and earth to ensure it will not be neccessary.

  1. In Australia and the UK all anaesthetists are doctors (ie. medical anaesthetists), so I use this term throughout interchangeably with 'anaesthesiologists' – although we are considering a name change to align with our North American peers. 

  2. Brendan Murphy had a rather long and fraught battle with a Melbourne Department of Anaesthesia, in which he belatedly discovered the heft of the specialty and it's one-for-all-and-all-for-one advocacy for work conditions, patient safety and anaesthesia services. The dominant theme revealed by Dr Murphy's public statements at the time was simply disbelief, betraying his lack of understanding of the considerable pride that anaesthetists take in the care they provide patients. 

  3. Also related and releveant is Daniel Kahneman's prospect theory, the foundation of modern behavioural economics, describing the asymmetry in how individuals assess risk from a loss and gain perspective – both our tendency to be 'loss-averse' but also how this may flip depending on the level of risk and the expected outcome of a decision. This has a lot of relevance to how the general public has responded to the COVID pandemic, however is different to 'asymmetric risk' which describes situations with disproportionate difference between magnitude of downside risk vs upside gain. 

  4. For bragging-rights, anaesthesia is the only specialty to have achieved six-sigma safety levels when considering anaesthesia-related deaths. Of course death is a very imperfect measure of anaesthesia quality – no anaesthetist would consider its avoidance even a minimum quality standard, quality is after all a multi-domain concept – but the incredible and purposeful improvement in anaesthesia safety since the 1950s is an impressive example of the prioritisation of safety by our entire specialty. Over 70 years we have brought about a 100-fold decrease in anaesthesia mortality through the work of many anaesthesia organisations and societies, bringing anaesthesia-related mortality down to a "6 sigma defect rate". In the manufacturing industry this describes a 99.99966% defect-free process, 3.4 'defects' per million or a 1 in 294,000 chance of dying due to an anaesthesia-related cause. Roughly comparable to the mortality data we have today.