Last week I placed an epidural for labor and delivery. The patient became comfortable without complications and expressed appreciation for my skills and knowledge. To another anesthesiologist, the procedure would have looked routine, but my experience was the opposite. Even before I started the procedure, my heart rate quickened, and I felt a disturbance in my gut. My hands quivered as I worked to find the epidural space. I was concerned that I might make the most minimal mistake or even a blunder. Until the patient reported that she was pain-free, I continued to feel anxious.

I am a fellowship-trained obstetric anesthesiologist with more than 20 years of experience. I have supervised and personally inserted thousands of regional anesthetics, and I remain calm and poised in the most stressful situations. This epidural was not customary because the patient was a nurse, married to the chief of cardiothoracic surgery. After two decades of practice, I have successfully acclimated to the stress and challenges of medicine, including functioning with minimal sleep, remaining composed when caring for critically ill patients, remembering a vast array of facts and being compassionate and caring toward patients and coworkers. When I give anesthesia to VIPs, coworkers and friends, though, I am anxious and apprehensive even as I am also honored and proud that my skills and knowledge are sought out. Under these unique circumstances, however, I do not have the same equanimity and composure I usually feel in the operating room. I am never cavalier or bold when performing my responsibilities, but I do have confidence and self-assurance commensurate with my many years of experience.

I surveyed my colleagues and found that many share my feelings; we love being asked to do a “special” anesthetic, but our joy ends when we start to anticipate and plan for the procedure. Positive emotions of pride, privilege and honor are frequently outweighed by unease and angst. I am no longer willing to “just put up” with the worry of conducting “special” anesthetics so I have given considerable thought to what drives my negativity and what I can do to minimize or eliminate my apprehensions.

No one has ever said why they asked for me. I have always assumed it was because they expected I would not make any mistakes. This assumption may be incorrect; regardless, the presumed goal is impossible to achieve. I consistently point out to my residents that they are not perfect. Despite their best efforts, they will occasionally require several attempts to place an intravenous catheter or spinal block. Epidural catheters they introduce will sometimes be intravascular, their patients will have wide swings in blood pressure during surgery and from time to time be undermedicated or overmedicated with narcotics. I need to take to heart my own teaching. The delivery of a flawless anesthetic is impossible to guarantee. Setting this unrealistic goal for myself is a recipe for anxiety and trepidation. Experts on physician behavior and personality have documented that the naïve ambition of never making a slip-up or oversight is a contributing factor in dissatisfaction with one’s occupation, conflicts with coworkers, troubles with personal relationships and addictive behavior. Maybe my friends or colleagues ask me to assist in their care because they want my compassion, humor and physical connection of a hand on the shoulder or a hug. I can guarantee these gifts to my patients without any risk of error or inaccuracy, and this support and cheer will more than make up for any minor miscalculation or technical mishap.

Concern for providing my patient with the perfect anesthetic is a distraction from my true mission: giving a safe anesthetic surrounded in reassurance and understanding. Sensitivity and emotionality are vital for supporting patients in the preoperative and postoperative periods. In the operating room, however, objective, clear-headed and targeted thinking and performance are the highest priorities. Personal feelings for the patient serve no constructive purpose and increase the chances of losing focus and making an error in judgment. When contemplating the plan for the “special” anesthetic, my first impulse is to change how I usually conduct the anesthetic and make it distinctive or exceptional. I discard what has worked well in the past for uncharted territory in an attempt to assure the patient that he or she is extraordinary. This scheme is fraught with trouble and can result in unforeseen events and negative outcomes. The optimal plan for the anesthetic should be “everything special, nothing different,” lots of TLC and standard techniques that have served me well over the last two decades.

A prevalent belief among physicians is that complications, both minor and major, are higher in patients who are nurses and doctors. The explanation for an infiltrated intravenous catheter, a difficult intubation or a spotty epidural is simply, “Oh, what do you expect? He’s a physician” or “she’s a nurse.” The notion that being a health care worker increases one’s susceptibility to complications is a rationalization for why the anesthetic is less than ideal. Instead of accepting the inherent liabilities of making complex decisions and performing intricate procedures, some physicians feel guilty that their medical care was not perfect, and instead of dealing with their feelings of failure, make the patient responsible for the less-than-perfect anesthetic.

The next time an associate, acquaintance or “bigwig” requests my personal attention, I will be flattered and grateful. Preoperatively I will assure the patient, both verbally and physically, that she or he is special, that I am concerned about him or her. My discussion will include optimism that the surgery and anesthetic will proceed safely and successfully. But I will also discuss the risks of the anesthetic in a frank and candid manner. Postoperatively I will apologize for any discomfort, disappointment or difficulties I may cause. Most importantly I will be kind and understanding toward myself. I will remember that I am a caring physician who is not perfect.

Frederick J. Spielman, M.D., is Professor and Vice-Chair, Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.