Perioperative care of complex medical patients requires seamless collaboration between internal medicine and anesthesiology. While internists provide invaluable expertise in chronic disease optimization and risk stratification, anesthetic decision-making is highly nuanced, dependent on intraoperative physiology, airway management, surgical considerations, and rescue contingencies. In some cases, well-intentioned recommendations from medical consultants regarding the preferred anesthetic technique may inadvertently overlook technical, pharmacologic, or safety considerations unique to anesthesiology practice. This chapter reviews three illustrative perioperative cases where internal medicine consultants suggested an anesthetic approach that, although theoretically beneficial, was less than optimal in practice. Each case highlights the anesthesiologist’s thought process, balancing risks and benefits, and offers respectful explanations. Through these scenarios, the chapter underscores that internists should focus their consultative input on medical optimization and risk communication, while avoiding prescriptive recommendations about anesthetic techniques. The anesthesiologist integrates the surgical requirements, airway management, hemodynamic implications, and intraoperative rescue strategies into the anesthetic plan. Effective perioperative collaboration relies on mutual respect and clear delineation of expertise, ensuring the best outcomes for complex patients.