Why Rational Decisions Keep Producing Bad Outcomes in Anesthesia

What We Reward, We Get — Even When We Don’t Like the Outcome

In anesthesia, many of our biggest problems are not the result of bad decisions. They are the result of rational decisions made inside bad incentive structures.

Under pressure, people optimize for what they’re rewarded and punished for. Hospitals, anesthesia groups, site leaders, and clinicians all respond to the scoreboards in front of them.

The problem is simple: those scoreboards increasingly reward short-term stability over long-term health. Once you see that, much of what feels chaotic or dysfunctional in anesthesia starts to look predictable.

Different Scorecards, Predictable Tension

Hospitals and anesthesia groups often say they want the same thing: safe, reliable anesthesia coverage that supports surgical growth. But they are scored differently.

• Hospitals are rewarded for OR uptime, throughput, service line stability, and avoiding disruption.

• Anesthesia groups are rewarded for labor stability, financial sustainability, recruitment success, and risk containment.

When a hospital pushes for an additional add-on room at 5:00 PM to capture revenue, they are being rational. When an anesthesia group hesitates because that room may trigger burnout-driven resignations and premium labor costs, they are also being rational.

Neither side is unreasonable. They’re optimizing against different dashboards. We call this a relationship problem or a communication gap. It isn’t. It’s incentive misalignment.

People behave in accordance with how they’re measured.

Leadership Under Incentive Pressure: The Accumulation of Cultural Debt

The deeper damage shows up inside leadership decisions. Under sustained pressure, smart leaders begin making locally rational but globally destructive calls.

I’ve seen this repeatedly: A struggling clinical leader erodes trust and drives strong clinicians away. Everyone knows it. But removing them would create temporary coverage gaps and tense hospital conversations. The short-term signal is loud. The long-term cost is quiet.

Short-term expedient. Long-term stupid.

We keep the “difficult” high-producer or the underperforming leader because we can calculate today’s staffing gap down to the hour. What we rarely calculate is the five resignations that follow, the recruitment fees, the months of premium labor, and the surgeons who quietly shift volume elsewhere.

By the time that cost shows up on a financial report, the original decision-maker is often gone. That is Cultural Debt. And like financial debt, it compounds.

This isn’t cowardice. It’s conditioning. When incentives reward calm surfaces and green dashboards, leaders learn that avoiding disruption is safer than creating it. Over time, entropy accumulates. The organization looks stable until it suddenly isn’t.

The Locums Release Valve

Which brings us to locum tenens. This isn’t a locums hit piece. Most clinicians choosing locums are responding rationally to the same incentive pressures shaping the rest of the system.

If locums is so detrimental to culture, cost, and continuity, why does it still feel rational? Because it solves a visible problem for everyone in the room.

• The clinician gains leverage and flexibility.

• The site leader keeps the board green.

• The hospital avoids the political and financial pain of a closed room.

In the short run, locums relieves pressure. And that’s exactly why it spreads. But the more the release valve works, the less urgency there is to fix the underlying structure. Dependence replaces strategy. Margin erodes quietly. Culture fragments slowly. The recruitment flywheel weakens.

Everyone involved is behaving rationally. Collectively, the system drifts.

The Question We Keep Avoiding

Systems don’t drift toward health. They drift toward whatever they reward, tolerate, or quietly incentivize. Before we debate staffing models or compensation redesign, there’s a simpler question:

What behavior are we currently paying for?

• If uptime is rewarded more than sustainability, structural problems will persist.

• If avoiding conflict is safer than addressing dysfunction, weak leadership will remain.

• If “butts in seats” matters more than cultural fit, locums and turnover will grow.

Until the scoreboard changes, asking people to behave differently is just asking them to act irrationally. And in anesthesia, that rarely works.

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The views expressed here are my own personal views and opinions and do not reflect the views of NorthStar Anesthesia.