How a focus on strength, frailty, and prehabilitation can change who wakes up feeling strong, who goes home and who never gets that chance.

I meet most of my patients on one of the most vulnerable mornings of their lives.

 They are shivering in thin gowns, covered with warm blankets that don’t quite reach their ankles, clutching clipboards and plastic cups of pre-op antiseptic. The fluorescent lights are too bright. The air smells like chlorhexidine and coffee. They are surrounded by strangers who are all using words like “case,” “turnover,” and “block time.”

On paper, they are “medically cleared.”

Their labs are acceptable. Their EKG is “unchanged.” Their cardiology note says “moderate risk, proceed.” Their primary care doctor has signed a form. The scheduler has found a spot on the OR grid.

But when I walk in as the anesthesiologist and sit down at eye level, what I see is different:

A patient who hasn’t walked a city block in months.

A protein intake closer to 30 grams than 90.
A CPAP machine still in its box because “I couldn’t get used to it.”
A Beers-criteria medication list (meds to avoid in older adults) that reads like a pharmacology exam

A terrified spouse at the bedside, whispering, “Will they be okay?”

Cleared? Yes.
Ready? Not even close.

The gap no one owns

We’ve built an entire system around clearance.

Clearance is binary. Pass/fail.
Checklist-driven. Orderable. Billable. “Satisfies guidelines.”

Readiness is different. Readiness is a spectrum. It’s dynamic. It’s about capacity, reserves, and trajectory. It’s “If something goes wrong, how much margin does this body have to handle it?”

As an anesthesiologist, I live in that gap.

I’m the one looking at the whole picture—heart, lungs, medications, nutrition, frailty, cognition, anxiety—and then trying to safely guide that human being through a physiologic hurricane.

The hard truth is: by the time they roll into my OR, the game is largely set. Whatever muscle mass they lost, whatever diabetes control they didn’t get, whatever sleep apnea that went undiagnosed for years—those are not things I can fix in a 15-minute pre-op visit and a bag of IV fluids.

Cleared, likely — rarely prepared. And yet, that’s when we finally ask the most all-encompassing question: “Are they okay for surgery?”

Surgery as a healthspan stress test

We talk about stress tests all the time in cardiology.

But surgery itself is a global stress test—for the heart, lungs, immune system, microbiome, brain, and family system. It’s one of the few moments when patients will show up, listen closely, and say, “Tell me what I can do to get through this and heal well.”

We have decades of evidence that prove:

•       Better nutrition and protein intake improve wound healing and strength.

•       Movement and strength before surgery change function afterwards.

•       Treating sleep apnea reduces complications and improves cognition.

•       Cleaning up medication lists—especially sedatives and certain psychoactive meds in older adults— and even simple brain-training activities reduces delirium and falls.

•       Simple education, repeated clearly and kindly, lowers anxiety and improves adherence.

•       And perhaps most importantly: the perioperative period is a documented “teachable moment,” a window when patients are uniquely motivated to change because the surgery date provides urgency and purpose.

And yet, most patients still arrive in pre-op having heard very little of this. They are rarely shown what meaningful preparation could actually look like. They assume the surgical conveyor belt will get them ready, and that if they follow the rules, the system itself will make them strong enough for success.

But unfortunately, “don’t eat after midnight” is not a readiness plan.

Two patients I won’t forget

Like most anesthesiologists, I carry a mental collage of patients who shaped how I see this work.

One is an older woman in her 70’s who came in after a femur fracture.

She lived alone. She’d been getting weaker for years in that slow, quiet way that never quite rises to the top of a clinic note. She was incontinent. Her appetite was poor. She needed help just to sit up in bed. Her frailty score was high. On paper, there wasn’t really a decision to be made: the urgent nature of a fractured femur meant she had no time to prepare or build any strength ahead of surgery.

We did everything we could to protect her.

We chose a spinal anesthetic with the lightest sedation possible. We tried to minimize the cognitive hit, the hemodynamic swings, the pain meds. Ortho did a good operation. The films looked fine.

But her body told the truth we already suspected.

The inflammatory surge, the pain, the immobility, the stress of hospitalization layered on top of years of dwindling reserves—it was all too much. Despite everyone’s best efforts, she never really recovered. She was discharged to a care facility and passed away there several days later.

Her story breaks my heart because nobody did anything “wrong.” We all did our jobs. And it still wasn’t enough. She is what it looks like when surgery collides with profound frailty and we never had a chance to build strength ahead of time.

Another patient is a woman, also about 70 years old, who came in for an elective total hip.

On paper, she was “older,” but she wasn’t frail. She had a primary care doctor who treated her upcoming surgery like something worth training for. She’d done prehabilitation—“prehab” for short—a set of simple, evidence-based steps that help patients build reserve before surgery: PT-guided movement, higher protein intake, and basic breathing work. She played memory games with her grandkids every day. Her meds had been tuned up. Her sleep was better. When I met her in pre-op, she looked like someone whose body still had reserves. You could see it in the small things: her veins were easy to find, her skin didn’t shear when we took the tape off, and her cheeks actually had color.

We approached her anesthetic with the same respect we’d given the previous patient: careful technique, thoughtful pain control, and close attention to blood pressure and cognition, but her starting line was completely different.

She did incredibly well.

She was up and walking quickly. Her pain was manageable. Her hospital stay was short. When I saw her again down the line, she was living her life, carrying that strength and readiness into everything that came after the surgery.

Those two patients, same rough age, same hospital, very different trajectories, live in my head every time I consent someone for anesthesia. Not as dramatic stories to tell, but as proof that readiness is not an abstract idea. It’s visible. It’s modifiable. And when we ignore it, the body will show us the difference anyway.

The problem isn’t that we don’t care

One of the things I want the public to understand is this: the problem is not that physicians don’t care.

We care deeply. It keeps us up at night.

We see the frail patient on the schedule and our stomachs drop. We even mark it on the chart in big red letters—FRAIL—from their frailty screening, because even when we haven’t had the chance to build muscle and strength ahead of time, simply naming it during a hospitalization can still change outcomes: choosing different or lighter anesthesia, being more careful with cognitive medications, mobilizing earlier, looping in geriatrics or PT.

The problem is that no one clearly owns the “readiness” lane.

•       Surgeons are drowning in consults, consent, and the actual operation.

•       Primary care physicians are buried under 15-minute visits and inboxes.

•       Anesthesiologists are often brought in late in the process, sometimes days before, sometimes hours before.

•       Pre-op clinics are tasked with “risk assessment and clearance,” not longitudinal optimization.

And layered on top of that are the usual suspects:

Insurance that doesn’t pay for “let’s get you stronger.”

Electronic records built around billing, not wisdom.

Guidelines that lag behind evidence by years.

A culture that praises heroics in the ICU but is strangely quiet about preventing the ICU stay in the first place.

Everyone is busy running their part of the race. No one is holding the baton at the first, most critical exchange.

What “ready” could look like

Readiness doesn’t have to be complicated to be meaningful.

When I imagine a better system, it looks something like this:

•      A simple surgical readiness score that goes beyond “ASA 3” and asks:

◦     How strong are you?

◦     How far can you walk?

◦     What’s your protein intake like? Are you hydrated?

◦     What does your memory look like?

◦     Are you sleeping? Snoring? Using CPAP?

◦     Who helps you at home?

•     Built-in prehabilation pathways for EVERY patient:

◦     Short, focused programs—2 to 6 weeks of movement, nutrition, and breathing work. Think of this as giving every patient a chance to become the strongest, most prepared version of themselves before they ever reach the OR.

◦     Telehealth where geography is a barrier.

◦     Not perfection, just upward trajectory.

•     Automatic medication audits:

◦     Looking for sedatives, anticholinergics, and meds that will make delirium, falls, and respiratory depression more likely.

•     CPAP and OSA taken seriously:

◦     Screening with tools like STOP-BANG.

◦     Helping people actually use their CPAP instead of leaving it in the closet.

•     Clear, kind education:

◦     Not a stack of photocopied sheets.

◦     Real conversations. Videos. Simple graphics. Family included.

◦     Repeated, not just handed over once and forgotten.

This doesn’t require a new miracle drug. It requires attention, ownership, and a shift in how we define “doing a good job.”

Who should own readiness?

In my ideal world, readiness would become:

•       A shared language between surgeons, anesthesiologists, and primary care.

•       A specialty identity for those of us who live in the perioperative space.

•       A normal expectation for patients.

Primary care is uniquely positioned to lead, because patients trust their PCP long before they ever meet the surgical team. But they can’t do it alone. Prehabilitation, perioperative medicine, anesthesia, rehab, nutrition, pharmacy—we’re all pieces of the same puzzle.

We need to stop treating readiness as “extra” and recognize it as what it is: the foundation.

Compassion for our patients—and for ourselves

I’m an anesthesiologist. I love the physiology, the pharmacology, the split-second decisions. But what keeps me in this work is not the ventilator settings or the vasopressor choices. It’s the human being under the drapes.

It’s the patient who tells me, in a shaking voice, “I’m really scared,” and the privilege of saying, “I hear you. I’m going to watch you every second. We’re in this with you.”

It breaks my heart that so many of them never hear, weeks earlier, “Here are three things you can do to feel stronger for this.”

I don’t think readiness will fix everything broken in medicine. But I do think it’s one of the few changes that could simultaneously:

•       Improve outcomes.

•       Restore meaning for physicians.

•       Give patients a sense of empowerment instead of helplessness.

A gentle challenge—and an invitation

If you’re reading this as a fellow physician—whatever your specialty—I’m not asking you to overhaul your practice overnight.

I am asking you to consider one question the next time you see a patient headed for surgery:

“Are they just cleared, or are they actually ready?”

And then, maybe:

•       Refer to Preoperative Medicine (if available), where clinicians can help initiate prehabilitation. If your town doesn’t have a dedicated perioperative clinic, consider leaning on surgery-specific physical therapists and dietitians who can support patients in building strength and improving nutrition.

•       Ask about protein, walking and cognitive strength in the same breath as NPO.

•       Look once more at that med list with an eye toward the hospital stay to come.

•       Say, out loud, “Your strength going into surgery matters. You’re not powerless here.”

Those small moments of honesty and encouragement might be the most important counseling we do.

I will keep standing at the head of the bed, doing everything I can to shepherd people safely through some of the hardest days of their lives. But I dream of a system where, when they arrive in my OR, they don’t just have a signed clearance note.

They have reserves. They have strength. They have a team that helped them get ready.

And they know, deeply, that their body was worth preparing.

If you feel that tug too—if you want to be part of shifting our culture from “cleared” to “ready”—join me in this Surgical Readiness Revolution.

Cherie Long is an Anesthesiologist in Oregon. She can be reached at Cherie@getglowprep.com.